Nursing Elites

1. The priority nursing diagnosis for a client with major depression is:

• A. Altered nutrition
• B. Altered thought process
• C. Self care deficit
• D. Risk for injury

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. Which systolic blood pressure measurement is classified as prehypertension?

• A. 106 mmHg
• B. 119 mmHg
• C. 130 mmHg
• D. 141 mmHg

Correct answer: B

Rationale: According to the blood pressure classification, a systolic blood pressure between 120-139 mmHg is considered prehypertension. This range indicates an increased risk for developing hypertension if not managed appropriately. Therefore, a systolic blood pressure of 119 mmHg falls into the prehypertension category. A systolic pressure of 106 mmHg is within the normal range, while 130 mmHg and above would be classified as stage 1 and stage 2 hypertension respectively, not prehypertension.

3. The breakdown in teamwork is often times a failure in:

• A. Electricity
• B. Inadequate supply
• C. Leg work
• D. Communication

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

4. A client with Crohn's disease is being cared for by a nurse. Which of the following food choices aligns with the recommended diet for clients with Crohn's disease?

• A. Vanilla milkshake
• B. Buttered popcorn
• C. Tossed green salad
• D. Toast with jelly

Correct answer: C

Rationale: The correct answer is a 'Tossed green salad.' Clients with Crohn's disease often benefit from a low-residue diet, which includes easily digestible foods like leafy green vegetables found in a tossed green salad. This type of diet helps minimize gastrointestinal symptoms. Choices A, B, and D are not ideal for clients with Crohn's disease. Vanilla milkshake, buttered popcorn, and toast with jelly may exacerbate symptoms due to their high fat, fiber, or sugar content, which can be harder to digest.

5. What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?

• A. Mrs. Guevarra makes the assignment to instruct the staff member
• B. Mrs. Guevarra is assigning the responsibility to the aide but not the accountability for those tasks
• C. Mrs. Guevarra does not need to directly supervise or evaluate the aide
• D. Mrs. Guevarra must know how to perform the task being delegated

Correct answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

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