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 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.

3. You notice that Miss Kate, a bread vendor, receives and changes money, then holds the bread without washing her hands. As a nurse, what should you say to Miss Kate?

• A. Miss, don't touch the bread, I'll be the one to pick it up.
• B. Miss, please wash your hands before you pick up the bread.
• C. Miss, use a pick-up forceps when picking up the bread.
• D. Miss, your hands are dirty, I guess I'll try another bread shop.

Correct answer: B

Rationale: The correct answer is B, as it emphasizes the importance of hygiene in food handling, which is crucial to prevent the spread of germs and diseases. The other options do not address the root of the issue, which is the unhygienic handling of food. Option A avoids direct confrontation but does not educate the vendor on proper hygiene. Option C, although it suggests a hygienic method, may not be practical or available in all situations. Option D is an avoidance strategy rather than a way to address the problem.

4. You are on duty in the medical ward. The mother of your patient who is also a nurse, came running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest.

• A. Start basic life support measures
• B. Call for the Code
• C. Bring the crash cart to the room
• D. Go to see Fiolo and assess for airway patency and breathing problems

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.

5. A breastfeeding mother complains that she missed her son's last two feedings and now her breasts have become full, hard, and uncomfortable. This condition is known as _____.

• A. mastitis
• B. engorgement
• C. letdown
• D. galactorrhea

Correct answer: B

Rationale: Engorgement occurs when the breasts become overly full, leading to discomfort and sometimes difficulty with latching. It can be relieved by feeding or expressing milk. Mastitis, choice A, is characterized by breast inflammation usually caused by an infection. Letdown, choice C, refers to the release of milk from the breast. Galactorrhea, choice D, is the spontaneous flow of milk from the breast unassociated with childbirth or nursing.

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