Nursing Elites

1. The healthcare provider is teaching a client with hypertension about lifestyle modifications. Which instruction should the healthcare provider include?

• A. Limit sodium intake to 2,300 mg per day
• B. Engage in moderate exercise for 30 minutes daily
• C. Consume a diet high in saturated fats
• D. Avoid alcohol consumption completely

Correct answer: B

Rationale: Engaging in moderate exercise for 30 minutes daily is a crucial lifestyle modification for managing hypertension. Regular physical activity helps lower blood pressure, improve cardiovascular health, and overall well-being. It is recommended to engage in activities like brisk walking, cycling, or swimming to achieve these benefits. Choices A, C, and D are incorrect. Limiting sodium intake, avoiding a diet high in saturated fats, and reducing alcohol consumption are also important lifestyle modifications for hypertension management, but engaging in moderate exercise is the most appropriate initial instruction for this client.

2. During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?

• A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing.
• B. The client tells the nurse that she does not have much of an appetite today.
• C. The nurse notes that there are numerous scatter rugs throughout the house.
• D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Correct answer: C

Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.

3. A client with a diagnosis of hyperthyroidism is being discharged. Which instruction should the nurse include in the discharge teaching?

• A. Avoid foods high in iodine.
• B. Take your medication with meals.
• C. Monitor your weight daily.
• D. Decrease your daily fluid intake.

Correct answer: A

Rationale: The correct answer is A: 'Avoid foods high in iodine.' Clients with hyperthyroidism should avoid foods high in iodine to prevent exacerbation of their condition. Iodine is an essential component in thyroid hormone production, and excessive iodine intake can worsen hyperthyroidism symptoms. Taking medication with meals (B) can interfere with the absorption of certain thyroid medications. Monitoring weight daily (C) is more relevant for conditions that may lead to weight changes like hypothyroidism. Decreasing fluid intake (D) is not a standard recommendation for hyperthyroidism unless specifically indicated by the healthcare provider.

4. What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?

• A. Maintain the client in a lateral position using protective wrist and vest restraints.
• B. Position the client prone with a small pillow below the diaphragm.
• C. Raise the head and knee gatch when lying in a supine position.
• D. Transfer the client to a wheelchair close to the nursing station for observation.

Correct answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients. Choice A is incorrect because using restraints can lead to further complications and does not address pressure relief. Choice C is incorrect as raising the head and knee gatch in a supine position does not directly alleviate pressure over the sacrum. Choice D is incorrect as transferring to a wheelchair does not address pressure relief or optimal positioning to prevent sacral ulcers.

5. Which assessment data indicates the need for the nurse to include the problem 'Risk for falls' in a client’s plan of care?

• A. Recent serum hemoglobin level of 16 g/dL
• B. Opioid analgesic received one hour ago
• C. Stooped posture with an unsteady gait
• D. Expressed feelings of depression

Correct answer: B

Rationale: The correct answer is B. The administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client’s care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.

Similar Questions