the nurse notes that the fall might also cause a possible head injury she will be observed for signs of increased intracranial pressure which include

ATI RN

Nutrition ATI Test

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. Starting material for sex hormones:

A. cholesterol
B. phospholipid
C. saturated
D. triglyceride

Correct answer: A

Rationale: Cholesterol is a precursor for the synthesis of sex hormones like estrogen and testosterone.

3. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:

A. Percussion uses only one hand, while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms, while vibration gently shakes secretions loose
C. In both percussion and vibration, the hands are not on top of each other, and hand action is not in tune with the client's breath
D. Percussion slaps the chest to loosen secretions, while vibration shakes the secretions along with the inhalation

Correct answer: D

Rationale: Chest percussion involves the use of rhythmic tapping to dislodge mucus from the lungs, facilitating its movement toward the larger airways where it can be expelled. This technique is particularly important in conditions where mucus retention is a significant risk factor for infection. The key difference between chest percussion and vibration is that percussion involves slapping the chest to loosen secretions, while vibration involves shaking the secretions along with the inhalation, aiding in moving the loosened secretions upwards for easier removal. Choices A, B, and C do not accurately describe the main difference between chest percussion and vibration, making them incorrect.

4. A nurse is providing anticipatory guidance to a client who has Phenylketonuria (PKU) and is planning a pregnancy. Which of the following information should the nurse include in the discussion?

A. Diet sodas should not be consumed more than two or three times a week.
B. Serum bilirubin should be monitored once or twice a month during pregnancy.
C. Breastfeeding will not prevent your baby from developing PKU.
D. A low-protein diet should be followed for three months before conception.

Correct answer: D

Rationale: A low-protein diet should be followed for three months before conception in individuals with PKU who are planning a pregnancy. This diet helps manage PKU by reducing phenylalanine levels, which is crucial for maternal and fetal health. Choices A, B, and C are incorrect. Choice A is not directly related to managing PKU, choice B focuses on a different aspect of care during pregnancy, and choice C is inaccurate as breastfeeding will not prevent a baby from developing PKU.