Nursing Elites

1. What is an essential nursing intervention for a client experiencing delirium?

• A. Control behavioral symptoms with low-dose psychotropics
• B. Identify the underlying causative condition
• C. Increase environmental stimulation
• D. Administer antipsychotic medication

Correct answer: B

Rationale: The correct answer is B - 'Identify the underlying causative condition.' When a client is experiencing delirium, it is crucial to determine the root cause of this acute change in mental status. This can involve a thorough assessment to identify any medical conditions, medications, infections, or environmental factors that may be contributing to the delirium. By pinpointing the underlying cause, appropriate interventions can be implemented to address the specific issue. Choices A, C, and D are incorrect because controlling behavioral symptoms with low-dose psychotropics, increasing environmental stimulation, and administering antipsychotic medication do not target the primary need of identifying and addressing the causative condition of delirium.

2. Which nursing intervention is essential for a client diagnosed with heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Increase sodium intake to prevent fluid retention
• D. Limit fluid intake to avoid overload

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with heart failure. This intervention helps healthcare providers evaluate fluid retention or loss, which is crucial in managing heart failure. Choice A is incorrect because excessive fluid intake can worsen heart failure symptoms by causing fluid overload. Choice C is incorrect because increasing sodium intake can lead to fluid retention, exacerbating heart failure. Choice D is incorrect as limiting fluid intake excessively can also be harmful in heart failure management, potentially leading to dehydration.

3. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

• A. A history of gastroesophageal reflux disease.
• B. Receiving a formula with high osmolarity.
• C. Sitting in a high-Fowler's position during the feeding.
• D. A residual of 65 mL 1 hour postprandial.

Correct answer: A

Rationale: The correct answer is A: A history of gastroesophageal reflux disease. Clients with gastroesophageal reflux disease have a higher risk of aspiration during tube feeding due to the potential for reflux of stomach contents into the lungs. This increases the risk of aspiration pneumonia. Choices B, C, and D are incorrect. High osmolarity formulas may cause diarrhea but do not directly increase the risk of aspiration. Sitting in a high-Fowler's position actually reduces the risk of aspiration by promoting proper digestion and reducing the chance of regurgitation. A residual of 65 mL 1 hour postprandial is within an acceptable range and does not directly indicate a risk for aspiration.

4. What should a healthcare professional assess in a patient presenting with symptoms of a stroke?

• A. Assess facial drooping
• B. Monitor speech difficulties
• C. Evaluate arm weakness
• D. Check for time of onset of symptoms

Correct answer: A

Rationale: When assessing a patient with suspected stroke symptoms, it is crucial to check for facial drooping as it can be a sign of facial nerve weakness, which is a common indicator of stroke. While monitoring speech difficulties and evaluating arm weakness are also important assessments in stroke cases, they are secondary to facial drooping. Checking for the time of onset of symptoms is essential to determine eligibility for time-sensitive treatments like thrombolytic therapy, but when prioritizing assessments, facial drooping takes precedence.

5. A nurse is teaching a client who has ulcerative colitis about dietary recommendations. Which of the following instructions should the nurse include?

• A. Avoid high-fiber foods
• B. Increase intake of spicy foods
• C. Consume foods high in fiber
• D. Eat large, infrequent meals

Correct answer: C

Rationale: The correct answer is C: 'Consume foods high in fiber.' Consuming high-fiber foods helps manage symptoms of ulcerative colitis by promoting regular bowel movements. Choices A, B, and D are incorrect. Avoiding high-fiber foods can worsen symptoms as fiber is beneficial for digestive health. Increasing the intake of spicy foods can exacerbate inflammation in the digestive tract, leading to more discomfort. Eating large, infrequent meals can put more strain on the digestive system, which is not ideal for managing ulcerative colitis.

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