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. For a patient on a ketogenic diet, which macronutrient is primarily increased?

• A. Carbohydrates
• B. Protein
• C. Fats
• D. Fiber

Correct answer: C

Rationale: The correct answer is C: Fats. A ketogenic diet is characterized by high fat intake, moderate protein intake, and very low carbohydrate intake. This diet aims to shift the body's metabolism to use fat as the primary source of energy instead of carbohydrates. Increasing fat intake while reducing carbohydrates is essential for achieving and maintaining a state of ketosis. Therefore, choices A, B, and D are incorrect as they do not align with the macronutrient adjustments required for a ketogenic diet.

3. An adolescent client has bloodshot eyes, a voracious appetite, and dry mouth. Which drug abuse would the nurse most likely suspect?

• A. Marijuana
• B. Amphetamines
• C. Barbiturates
• D. Anxiolytics

Correct answer: A

Rationale: The symptoms described, including bloodshot eyes, a voracious appetite, and dry mouth, are consistent with marijuana use. Bloodshot eyes are a common side effect of marijuana due to its effect on blood vessels in the eyes. Marijuana also often causes an increase in appetite (known as 'the munchies') and can result in dry mouth. Amphetamines typically cause symptoms like increased alertness, energy, and decreased appetite. Barbiturates and anxiolytics would not typically cause bloodshot eyes, a voracious appetite, and dry mouth as described in the scenario. Therefore, the most likely drug abuse the nurse would suspect in this case is marijuana.

4. Causes of acute renal failure include:

• A. chronic renal failure
• B. uncontrolled diabetes mellitus
• C. recurrent urinary tract infections
• D. severe injury such as extensive burns

Correct answer: D

Rationale: The correct answer is D. Severe injuries, like extensive burns, can cause acute renal failure due to shock, reduced blood flow to the kidneys, and tissue damage. Choices A, B, and C are incorrect because chronic renal failure, uncontrolled diabetes mellitus, and recurrent urinary tract infections are more likely to contribute to chronic kidney disease rather than acute renal failure.

5. Each statement is true, except one. Which is the exception?

• A. Infant formulas should be discontinued at approximately 1 year of age
• B. Low-fat milk is not recommended for children younger than 2 years
• C. Special toddler formulas are available but are unnecessary
• D. Vitamin D-fortified whole milk should not be provided until 2 years

Correct answer: D

Rationale: The correct answer is D. Vitamin D-fortified whole milk should be provided starting at age 1 after discontinuing breast feeding or infant formulas, not at 2 years. Providing whole milk at age 2 is appropriate. Choices A, B, and C are correct statements: infant formulas are typically discontinued around 1 year of age, low-fat milk is not recommended for children under 2 years, and special toddler formulas are unnecessary.

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