Nursing Elites

1. The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:

• A. Narrowing of the pulse pressure
• B. Vomiting
• C. Periorbital edema
• D. A positive Kernig's sign

Correct answer: C

Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.

2. Of the following neurotransmitters, which demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

• A. Serotonin
• B. Enkephalin
• C. Norepinephrine
• D. Acetylcholine

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

3. Which is NOT a prudent recommendation for a menopausal patient?

• A. Supplement calcium and vitamin D slightly beyond upper intake level
• B. Encourage lean protein and regular exercise
• C. Avoid alcohol if xerostomia is present
• D. Consumption of 90 mg daily of isoflavones in soy products helps to increase bone mass

Correct answer: A

Rationale: Excessive supplementation of calcium and vitamin D beyond the upper intake level is not recommended unless under medical supervision, as it can cause adverse health effects.

4. What is the priority nursing goal for an adolescent with anorexia nervosa?

• A. Encourage effective coping skills
• B. Restore normal eating habits
• C. Stop weight loss or restore weight
• D. Promote realistic self-image

Correct answer: C

Rationale: The priority nursing goal for an adolescent with anorexia nervosa is to stop weight loss or restore weight. This is crucial in addressing the immediate health risks associated with anorexia nervosa, such as malnutrition, organ damage, and potential life-threatening complications. While encouraging effective coping skills, restoring normal eating habits, and promoting a realistic self-image are important aspects of treatment, stopping weight loss or restoring weight takes precedence due to the severe physical consequences of anorexia nervosa.

5. During an initial visit with an older adult client living alone and having difficulty preparing meals, what should the home health nurse do first?

• A. Discuss nutritional requirements with the client.
• B. Refer the client to a senior citizen center.
• C. Arrange for a home-delivered meal program.
• D. Perform a nutrition screening.

Correct answer: D

Rationale: Performing a nutrition screening is the most appropriate action for the nurse to take first. This allows the nurse to assess the client's current nutritional status and identify any specific needs. Discussing nutritional requirements with the client (Choice A) may be important but should come after the initial assessment. Referring the client to a senior citizen center (Choice B) or arranging for a home-delivered meal program (Choice C) are actions that may be considered later based on the findings of the nutrition screening.

Similar Questions