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. Which item is typically fortified with iodine to address iodine deficiency in the population?

• A. Flour
• B. Salt
• C. Canned vegetables
• D. Drinking water

Correct answer: B

Rationale: Iodized salt is the correct answer. Iodine deficiency can lead to thyroid problems, so iodine is added to salt to ensure an adequate intake of this essential nutrient. Flour is often fortified with other nutrients like folic acid, iron, and niacin, but not iodine. Canned vegetables and drinking water are not typically fortified with iodine to address deficiency in the population.

3. A client receiving continuous enteral tube feeding reports cramping and abdominal distention. Which of the following actions should the nurse take?

• A. Check for gastric residual.
• B. Apply low intermittent suction.
• C. Increase the rate of the feeding.
• D. Request a higher-fat formula.

Correct answer: A

Rationale: When a client on continuous enteral tube feeding experiences cramping and abdominal distention, the nurse should check for gastric residual. This assessment helps determine if the client is tolerating the feeding well or if there is a potential issue such as feeding intolerance. Applying low intermittent suction, increasing the feeding rate, or requesting a higher-fat formula are not appropriate actions for addressing the reported symptoms and may exacerbate the client's discomfort or lead to further complications.

4. Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?

• A. Self-esteem disturbance
• B. Impaired urinary elimination
• C. Impaired skin integrity
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.

5. What condition has been shown to be associated with esophageal dysphagia?

• A. myasthenia gravis
• B. achalasia
• C. Alzheimer's disease
• D. cerebral palsy

Correct answer: B

Rationale: Achalasia is the correct answer. It is a condition characterized by the esophagus having difficulty moving food toward the stomach, resulting in dysphagia (difficulty swallowing). Myasthenia gravis (Choice A) is a neuromuscular disorder that affects skeletal muscles, not the esophagus. Alzheimer's disease (Choice C) primarily affects cognitive function, not the esophagus. Cerebral palsy (Choice D) is a neurological disorder affecting body movement and muscle coordination, unrelated to esophageal dysphagia.

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