Nursing Elites

1. When observing a newly admitted elderly client with dementia resisting care, what approach should the nurse take to facilitate cooperation?

• A. Use short, simple sentences and maintain a calm demeanor
• B. Involve family members to provide reassurance
• C. Offer choices to empower the client
• D. All of the above

Correct answer: D

Rationale: When dealing with a newly admitted elderly client with dementia who is resistant to care, it is crucial to employ multiple strategies to facilitate cooperation. Using short, simple sentences and maintaining a calm demeanor can help the client better understand instructions and reduce agitation. Involving family members can provide comfort and reassurance to the client, potentially decreasing resistance. Offering choices allows the client to feel a sense of control and autonomy in their care, which can increase cooperation and reduce challenging behaviors. Therefore, a combination of clear communication, family involvement, and providing choices is essential to effectively engage and care for a client with dementia. Choices A, B, and C all play crucial roles in addressing the needs of the client, making 'All of the above' the correct answer.

2. A client is prescribed warfarin for the prevention of thromboembolism. What dietary instruction should the nurse provide?

• A. Increase intake of green leafy vegetables
• B. Maintain a consistent intake of vitamin K-rich foods
• C. Avoid all foods containing vitamin K
• D. Consume a high-protein diet

Correct answer: B

Rationale: The correct answer is B. Maintaining a consistent intake of vitamin K-rich foods is important for patients taking warfarin as it helps keep the effects of the medication stable. Choice A is incorrect because while green leafy vegetables are high in vitamin K, they should not be avoided completely but rather consumed consistently. Choice C is also incorrect as avoiding all foods containing vitamin K can lead to fluctuations in warfarin's effectiveness. Choice D is incorrect as a high-protein diet is not specifically recommended for patients taking warfarin.

3. The client with high blood pressure is being taught by the nurse to avoid adding salt during cooking. What effect does sodium have on blood pressure?

• A. It decreases the viscosity of blood
• B. It leads to increased fluid retention
• C. It causes vasoconstriction of the blood vessels
• D. It enhances the excretion of potassium

Correct answer: C

Rationale: The correct answer is C: 'It causes vasoconstriction of the blood vessels.' Sodium can lead to vasoconstriction, which narrows the blood vessels, increasing resistance to blood flow and subsequently raising blood pressure. Choices A, B, and D are incorrect. Sodium does not decrease blood viscosity, but it can lead to fluid retention, which increases blood volume and pressure. It does not enhance the excretion of potassium; instead, high sodium intake can lead to potassium excretion by the kidneys.

4. During a routine prenatal visit, a nurse measures a client’s fundal height. The client is 26 weeks pregnant. What should the fundal height be?

• A. Approximately 26 cm
• B. Between 24 to 28 cm
• C. Above the umbilicus by two finger widths
• D. Below the xiphoid process

Correct answer: B

Rationale: The correct answer is B: Between 24 to 28 cm. Fundal height corresponds to the weeks of gestation, so at 26 weeks of pregnancy, the fundal height should range between 24 to 28 cm. This measurement is a quick way to assess fetal growth and amniotic fluid volume. Choice A is incorrect because fundal height may vary and not always match the exact weeks of pregnancy. Choice C, measuring above the umbilicus by two finger widths, is not a standard method for fundal height measurement. Choice D, below the xiphoid process, is too high and not relevant for assessing fundal height during pregnancy.

5. A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the nurse implement to prevent complications associated with Pneumonia?

• A. Encourage mobilization and ambulation
• B. Encourage energy conservation with complete bed rest
• C. Provide humidified oxygen via nasal cannula
• D. Restrict oral (PO) and intravenous fluids

Correct answer: A

Rationale: The correct intervention to prevent complications associated with pneumonia is to encourage mobilization and ambulation. These activities help prevent complications such as atelectasis by promoting lung expansion. Encouraging energy conservation with complete bed rest (Choice B) is not ideal as it can lead to complications like muscle weakness and decreased lung expansion. Providing humidified oxygen via nasal cannula (Choice C) is important in pneumonia treatment but does not directly prevent complications associated with pneumonia itself. Restricting oral (PO) and intravenous fluids (Choice D) is not recommended as adequate hydration is crucial for pneumonia patients to maintain respiratory function and overall health.

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