Nursing Elites

1. What breakfast selection indicates appropriate dietary management for osteoporosis?

• A. Pancakes with syrup and orange juice
• B. Bagel with jelly and skim milk
• C. Eggs with sausage and whole milk
• D. French toast with butter and syrup

Correct answer: B

Rationale: The correct answer is B. A bagel with jelly and skim milk is a calcium-rich and low-fat option that aligns with the dietary recommendations for managing osteoporosis. Osteoporosis is a condition characterized by weak and brittle bones, so it is essential to consume an adequate amount of calcium while avoiding excess fat intake. Choices A, C, and D are not ideal for osteoporosis management as they either lack sufficient calcium, contain high fat content, or both.

2. The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to

• A. Limit the effects of tissue damage
• B. Relieve pain and anxiety
• C. Prevent arrhythmias
• D. Reduce anxiety

Correct answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

3. The nurse is caring for a client with a traumatic brain injury who is receiving mechanical ventilation. Which assessment finding indicates that the client may be experiencing increased intracranial pressure (ICP)?

• A. Client becomes increasingly lethargic
• B. Client's respiratory rate is 16 breaths per minute
• C. Client responds to verbal stimuli
• D. Client's pupils are equal and reactive

Correct answer: A

Rationale: Increased lethargy is a sign of worsening intracranial pressure, which can be life-threatening in clients with brain injuries. As ICP rises, it can lead to decreased level of consciousness, such as lethargy or even coma. Choices B, C, and D are not indicative of increased ICP. A normal respiratory rate, response to verbal stimuli, and equal reactive pupils do not specifically point towards increased intracranial pressure.

4. The client provides three positive responses to the CAGE questionnaire. Which interpretation should the nurse provide?

• A. The CAGE is a tool for identifying substance abuse.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response indicates potential alcohol issues.
• D. All responses must be positive for alcohol dependence.

Correct answer: B

Rationale: The CAGE questionnaire is a widely used screening tool for alcohol dependence. Two or more positive responses suggest a higher likelihood of alcohol dependence. One positive response may indicate potential alcohol issues, but two or more significantly increase the likelihood of dependence. Therefore, choice B is the most appropriate interpretation. Choice A is incorrect because the CAGE questionnaire specifically focuses on alcohol-related issues, not substance abuse in general. Choice C is incorrect as one positive response does not indicate addiction but rather raises a concern. Choice D is incorrect as not all responses need to be positive to suggest alcohol dependence.

5. Which statement made by the client indicates an understanding of the instructions regarding the administration of alendronate (Fosamax)?

• A. I will take the medication at bedtime to avoid stomach upset.
• B. I will take the medication with a full glass of water first thing in the morning.
• C. I will lie down for 30 minutes after taking the medication.
• D. I will take the medication with food to reduce stomach irritation.

Correct answer: B

Rationale: The correct answer is B. Alendronate (Fosamax) should be taken with a full glass of water in the morning to prevent esophageal irritation and ensure proper absorption. Choice A is incorrect because taking alendronate at bedtime increases the risk of esophageal irritation due to lying down. Choice C is incorrect because patients should remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation. Choice D is incorrect because alendronate should be taken on an empty stomach, not with food, to enhance absorption.

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