Nursing Elites

1. What are the signs of an acute myocardial infarction?

• A. Chest pain radiating to the arm and shortness of breath
• B. Nausea, vomiting, and high fever
• C. Headache, confusion, and low blood pressure
• D. Increased heart rate and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.

2. A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN - 25, K+ - 4.0 mEq/L. Which nutrient should be restricted in the client's diet?

• A. Protein
• B. Fats
• C. Carbohydrates
• D. Magnesium

Correct answer: A

Rationale: In clients with oliguria, hypertension, and peripheral edema, protein should be restricted in the diet to reduce the workload on the kidneys. Excessive protein intake can lead to increased BUN levels, which can further stress the kidneys. Restricting protein can help prevent further kidney damage. Fats, carbohydrates, and magnesium do not directly impact kidney function in the same way as protein does, making them incorrect choices in this scenario.

3. A nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?

• A. I am frustrated that I cannot lift my arm to comb my hair.
• B. I am upset that I can't hold a pencil anymore.
• C. I am embarrassed that I cannot open my milk carton.
• D. I am so frustrated that I cannot even open my milk carton for breakfast.

Correct answer: D

Rationale: The correct answer is D because the inability to perform activities of daily living, such as opening a milk carton, suggests difficulties with fine motor skills. Occupational therapists specialize in helping individuals regain independence in such tasks. Choices A, B, and C do not specifically address fine motor skills related to activities of daily living, therefore not warranting an occupational therapy referral. Choice A mentions lifting the arm, which involves gross motor skills rather than fine motor skills. Choice B involves holding a pencil, which is more related to hand dexterity and strength rather than fine motor skills. Choice C, opening a milk carton, could be related to fine motor skills but is not as clear-cut as the inability described in Choice D, where the frustration is explicitly about the inability to perform a daily living task.

4. A nurse is caring for a client following an acute myocardial infarction who is concerned about fatigue. What is the best strategy to promote independence in self-care?

• A. Instruct the client to remain in bed until the fatigue resolves
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to perform all self-care tasks for the client
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence while managing fatigue. This approach allows the client to regain confidence in their abilities and fosters independence. Option A is incorrect as prolonged bed rest can lead to deconditioning and worsen fatigue. Option C is not promoting independence as it involves delegating all self-care tasks to others. Option D involves family assistance, which may be helpful but does not directly promote the client's independence in self-care.

5. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?

• A. The client has slight edema of the eyelids
• B. There is clear fluid draining from the client's right ear
• C. There is some bleeding from the child's lacerations
• D. The client withdraws in response to painful stimuli

Correct answer: B

Rationale: Clear fluid draining from the ear can indicate cerebrospinal fluid leakage, which is a serious concern after a head injury. This leakage can signify a skull fracture or damage to the meninges, potentially leading to infection. Therefore, it should be reported immediately for further evaluation and management. Choices A, C, and D are typical findings after head trauma and are not as urgent as the presence of clear fluid draining from the ear.

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