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. What are sheets/forms that provide an efficient and time-saving way to record information that must be obtained repeatedly at regular and/or short intervals of time? This does not replace progress notes; instead, it records information on vital signs, intake and output, treatment, postoperative care, postpartum care, and diabetic regimen, etc. These are used whenever specific measurements or observations need to be documented repeatedly. What is this?

• A. Nursing Kardex
• B. Graphic Flow Sheets
• C. Discharge Summary
• D. Medicine and Treatment Record

Correct answer: A

Rationale: The correct answer is A, Nursing Kardex. Nursing Kardex is a tool used for documenting essential patient information that needs to be recorded repeatedly at regular intervals. It includes vital signs, intake and output, treatment details, postoperative care, postpartum care, and diabetic regimen. This tool is efficient and time-saving for healthcare professionals. Choice B, Graphic Flow Sheets, may be used for visual representation of patient data but is not specifically designed for repeated documentation of essential information. Choice C, Discharge Summary, is a document outlining the patient's care and condition at the time of discharge, not for repeated recording of ongoing data. Choice D, Medicine and Treatment Record, focuses more on specific medications and treatments rather than a comprehensive recording of various patient data needed at regular intervals.

3. 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.

4. A nurse is providing teaching to the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include?

• A. Sliced bananas
• B. Raw celery
• C. Peanut butter
• D. Grapes

Correct answer: A

Rationale: The correct answer is sliced bananas. Bananas are a good choice for toddlers as they are easy to chew, rich in potassium, and generally well-tolerated. Raw celery (Choice B) may pose a choking hazard due to its fibrous nature. Peanut butter (Choice C) should be avoided as it can also be a choking hazard and may cause an allergic reaction in some children. Grapes (Choice D) are a choking hazard for toddlers due to their size and shape, so they should be cut into smaller pieces or avoided altogether.

5. Which is NOT a classification of carbohydrate?

• A. Monosaccharides
• B. Disaccharides
• C. Polysaccharides
• D. Triglycerides

Correct answer: D

Rationale: The correct answer is D, Triglycerides. Triglycerides are a type of fat, not a carbohydrate. Monosaccharides, disaccharides, and polysaccharides are all classifications of carbohydrates based on the number of sugar units they contain. Monosaccharides are the simplest form with one sugar unit, disaccharides contain two sugar units, and polysaccharides have multiple sugar units linked together.

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