Nursing Elites

1. Which of the following actions would be of highest priority with regards to the external shunt?

• A. Avoid taking blood pressure or blood sample from the arm with the shunt
• B. Instruct the patient not to exercise the arm with the shunt
• C. Heparinize the shunt daily
• D. Change the dressing of the shunt daily

Correct answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

2. A nurse is teaching a group of clients about stress. Which of the following should the nurse include in the teaching?

• A. Protein requirements decrease in times of stress.
• B. Acute stress causes an increase in metabolism.
• C. Stress causes a positive nitrogen balance in the body.
• D. Glucose is broken down more slowly during times of stress.

Correct answer: B

Rationale: The correct answer is B: Acute stress causes an increase in metabolism. During acute stress, the body's fight-or-flight response is activated, leading to an increase in metabolism to provide energy for the body to respond to the stressor. Choices A, C, and D are incorrect. Protein requirements actually increase during times of stress to support the body's needs. Stress typically leads to a negative nitrogen balance in the body, not a positive one. Glucose is broken down more rapidly, not slowly, during times of stress to provide immediate energy.

3. Wernicke-Korsakoff syndrome is associated with which vitamin deficiency?

• A. Thiamine (B1)
• B. Riboflavin (B2)
• C. Niacin (B3)
• D. Pyridoxine (B6)

Correct answer: A

Rationale: Wernicke-Korsakoff syndrome is indeed associated with thiamine (vitamin B1) deficiency. This syndrome is commonly seen in individuals with chronic alcoholism due to poor diet and impaired thiamine absorption. Thiamine is essential for normal brain function and energy metabolism. Riboflavin (B2) deficiency can lead to symptoms like sore throat and swollen mucous membranes, not Wernicke-Korsakoff syndrome. Niacin (B3) deficiency causes pellagra, characterized by dermatitis, diarrhea, dementia, and death, but not Wernicke-Korsakoff syndrome. Pyridoxine (B6) deficiency can result in dermatitis, glossitis, and peripheral neuropathy, but it is not associated with Wernicke-Korsakoff syndrome.

4. 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.

5. Which of the following is a normal change observed in an elderly individual?

• A. Enhanced sense of taste
• B. Increased appetite
• C. Frequent urination
• D. Lens thinning

Correct answer: C

Rationale: The correct answer is C, frequent urination. As people age, they may experience physiological changes that can lead to an increased frequency of urination. This is due to a decrease in bladder capacity and increased bladder irritability, which are normal age-related changes. On the contrary, the sense of taste (Choice A) and appetite (Choice B) often decrease with age, not increase. As for Choice D, the lens of the eye actually thickens with age, not thins, leading to conditions like presbyopia. Therefore, Choices A, B, and D are incorrect.

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