Nursing Elites

1. During the admission assessment of a 3-year-old with bacterial meningitis and hydrocephalus, which assessment finding is evidence of increased intracranial pressure (ICP)?

• A. Low blood pressure
• B. Increased respiratory rate
• C. Normal pupil reaction
• D. Sluggish and unequal pupillary responses

Correct answer: D

Rationale: Sluggish and unequal pupillary responses are indicative of increased intracranial pressure (ICP) in a child with bacterial meningitis and hydrocephalus. This finding suggests that the optic nerve is being compressed due to increased ICP, causing a delay in pupillary reactions. Such a delay is a critical sign of worsening ICP and necessitates immediate intervention. Low blood pressure and increased respiratory rate can occur in various conditions but are less specific to increased ICP than sluggish and unequal pupillary responses, which directly reflect neurological compromise.

2. The nurse is developing a plan of care for a client who reports tingling in the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?

• A. The client will walk 30 minutes three times a week
• B. The client will demonstrate understanding of proper shoe fit
• C. The client will perform foot care daily
• D. The client's blood pressure readings will be less than 160/90 mmHg

Correct answer: D

Rationale: Controlling blood pressure is critical in managing peripheral vascular disease, as elevated pressure can exacerbate vascular damage and complications. While foot care, shoe fit, and exercise are important, lowering blood pressure is a primary goal. Proper blood pressure management helps in preventing further damage to the blood vessels and reduces the risk of complications associated with peripheral vascular disease, making it the most crucial outcome to include in the plan of care for this client.

3. A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?

• A. Monitor the client’s liver function tests.
• B. Monitor the client’s prothrombin time (PT).
• C. Monitor the client’s partial thromboplastin time (PTT).
• D. Monitor the client’s red blood cell count.

Correct answer: C

Rationale: The correct answer is C: Monitor the client’s partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.

4. A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?

• A. Assess for signs of infection.
• B. Monitor the client’s fluid intake and output.
• C. Check the client’s capillary blood glucose level.
• D. Assess the client’s serum potassium level.

Correct answer: C

Rationale: The correct answer is to check the client’s capillary blood glucose level first. In a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, assessing blood glucose levels is crucial to confirm hyperglycemia and initiate appropriate interventions. While signs of infection are important to assess due to the client's postoperative status and diabetic history, checking the blood glucose level takes precedence to address the immediate concern of hyperglycemia. Monitoring fluid intake and output is essential but not the priority in this scenario. Assessing the client’s serum potassium level is important for overall assessment but not the initial step when hyperglycemia is suspected.

5. What are the primary pathophysiological mechanisms responsible for ascites in liver failure?

• A. Decreased liver enzymes.
• B. Increased hydrostatic pressure in portal circulation.
• C. High bilirubin levels.
• D. Fluid shifts due to decreased serum proteins.

Correct answer: B

Rationale: The correct answer is B: Increased hydrostatic pressure in portal circulation. Ascites in liver failure is primarily caused by fluid shifts from the intravascular space to the interstitial space due to increased hydrostatic pressure in the portal circulation. Choice A is incorrect as ascites is not caused by decreased liver enzymes. Choice C is incorrect as high bilirubin levels are not the primary mechanism for ascites in liver failure. Choice D is incorrect as fluid shifts in ascites are due to decreased serum proteins, not increased serum proteins.

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