Nursing Elites

1. What is the most important intervention for a client with delirium?

• A. Administer sedative medication
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Increase environmental stimulation

Correct answer: B

Rationale: The correct answer is to identify any reversible causes of delirium. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. Addressing these underlying causes can help resolve delirium. Administering sedative medication (Choice A) can worsen delirium by further altering mental status. Providing a low-stimulation environment (Choice C) is helpful to manage delirium symptoms, but it is not the most important intervention. Increasing environmental stimulation (Choice D) is contraindicated in delirium as it can exacerbate confusion and agitation.

2. A client with a new prescription for prednisone for the treatment of Addison's disease needs teaching. Which instruction should the nurse include?

• A. Take the medication with food
• B. Avoid taking aspirin
• C. Schedule a bone density test
• D. Expect increased appetite

Correct answer: C

Rationale: The correct instruction for the nurse to include is to schedule a bone density test. Prednisone can lead to reduced bone density, making regular monitoring crucial for clients on long-term therapy. Instructing the client to take the medication with food (choice A) or avoid taking aspirin (choice B) are not directly related to prednisone therapy for Addison's disease. While prednisone can cause increased appetite, it is not the priority instruction in this scenario, compared to monitoring bone density (choice D).

3. A nurse is caring for a client who is postoperative following a thyroidectomy. The nurse should monitor for which of the following findings as a sign of hypocalcemia?

• A. Nausea
• B. Tingling in the fingers
• C. Numbness in the toes
• D. Sweating

Correct answer: B

Rationale: Tingling in the fingers is a classic sign of hypocalcemia. Following a thyroidectomy, hypocalcemia can occur due to damage to the parathyroid glands, which regulate calcium levels in the body. Nausea, numbness in the toes, and sweating are not specific signs of hypocalcemia. Numbness and tingling usually start in the hands and feet due to their increased nerve sensitivity to low calcium levels.

4. What are the nursing interventions for a patient with neutropenia?

• A. Monitor for signs of infection and administer antibiotics
• B. Isolate the patient and provide a low-microbial diet
• C. Monitor vital signs and avoid unnecessary invasive procedures
• D. Encourage the patient to engage in social activities

Correct answer: A

Rationale: The correct nursing interventions for a patient with neutropenia include monitoring for signs of infection and administering antibiotics. Neutropenia is characterized by a low neutrophil count, which increases the risk of infections. Monitoring for signs of infection allows for early detection and prompt treatment, while administering antibiotics helps prevent or treat any infections that may occur. Isolating the patient and providing a low-microbial diet (Choice B) are not necessary unless the patient develops an active infection. Monitoring vital signs and avoiding unnecessary invasive procedures (Choice C) are important but do not specifically address the increased infection risk in neutropenic patients. Encouraging the patient to engage in social activities (Choice D) is not appropriate for a neutropenic patient due to the risk of exposure to infectious agents.

5. A nurse is teaching a client with heart failure about dietary restrictions. What food should be limited?

• A. Bananas
• B. Leafy green vegetables
• C. Potatoes
• D. Whole grains

Correct answer: A

Rationale: The correct answer is A: Bananas. Bananas are high in potassium, which should be limited in clients with heart failure to prevent electrolyte imbalances. While leafy green vegetables and whole grains are generally healthy options, they are not typically restricted in heart failure patients. Potatoes, although they contain potassium, are not as high in potassium as bananas and are not usually restricted as strictly.

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