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 group is least susceptible to insufficient intake of protein?

• A. The elderly
• B. Individuals with low income
• C. Adults participating in endurance exercise
• D. Patients who are chronically ill

Correct answer: C

Rationale: Adults who participate in endurance exercise are typically more aware of their nutritional needs and have higher protein intake compared to other groups. The rationale behind why the other choices are incorrect is as follows: A: The elderly are often at a higher risk of insufficient protein intake due to various factors such as reduced appetite, dental issues, and decreased muscle mass. B: Individuals with low income may struggle to afford protein-rich foods, making them more susceptible to insufficient protein intake. D: Patients who are chronically ill may have specific dietary restrictions or challenges that can lead to inadequate protein consumption.

3. What laboratory value would be considered a high-risk measure for coronary heart disease assessment?

• A. triglycerides > 150 mg/dL
• B. BMI > 31
• C. LDL cholesterol < 128 mg/dL
• D. blood pressure of 128/82 mmHg

Correct answer: B

Rationale: The correct answer is B: BMI > 31. A BMI over 31 is considered a high-risk factor for coronary heart disease as it indicates obesity, which is strongly linked to cardiovascular issues. Triglycerides > 150 mg/dL (choice A) can contribute to heart disease risk but are not as specific as BMI in assessing overall risk. LDL cholesterol < 128 mg/dL (choice C) is actually a desirable level, indicating lower risk. A blood pressure of 128/82 mmHg (choice D) is within normal range and not a high-risk measure specifically for coronary heart disease.

4. Which of the following is a poor food source of iron?

• A. Dried fruits
• B. Cheese
• C. Clams
• D. Legumes

Correct answer: B

Rationale: Iron is an essential nutrient for the body, and while it can be found in many different types of foods, the amounts can vary significantly. Cheese, while a good source of other nutrients like calcium and protein, is not a particularly rich source of iron. On the other hand, clams, legumes, and dried fruits are known to contain higher levels of iron. Therefore, among the provided choices, cheese is considered a poor source of iron. It's important to note that a balanced diet should include a variety of foods to ensure the intake of all necessary nutrients.

5. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care visit typically made?

• A. Within 4 days after discharge
• B. Within 24 hours after discharge
• C. Within 1 hour after discharge
• D. Within 1 week of discharge

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.

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