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. A client with celiac disease should avoid which of the following?

• A. Quinoa
• B. Barley
• C. Rice
• D. Oats

Correct answer: B

Rationale: The correct answer is B: Barley. Barley contains gluten, which is harmful to individuals with celiac disease. Gluten triggers an immune response in people with celiac disease, damaging the lining of the small intestine. Choices A, C, and D (Quinoa, Rice, and Oats) are gluten-free and safe for individuals with celiac disease to consume.

3. Maria’s statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” is an example of:

• A. Delusion of grandeur
• B. Visual Hallucination
• C. Religious delusion
• D. Auditory Hallcucination

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

4. A nurse is planning care for a client who has ascites secondary to liver disease. Which of the following interventions should the nurse include in the plan of care?

• A. Reduce complex carbohydrates to 30% of total calories.
• B. Restrict protein intake to less than 0.8 g/kg/day.
• C. Decrease daily caloric intake by 20%.
• D. Limit sodium to 2000 mg or less per day.

Correct answer: D

Rationale: The correct answer is to limit sodium to 2000 mg or less per day. Ascites, which is the abnormal accumulation of fluid in the abdominal cavity, is commonly associated with liver disease. Limiting sodium intake helps manage fluid retention by reducing the fluid accumulation in the abdomen. Choices A, B, and C are incorrect because reducing complex carbohydrates, restricting protein intake, or decreasing caloric intake are not the primary interventions for managing ascites in liver disease.

5. Ms. ANA had a car accident where he lost her boyfriend. As a result, she became passive and submissive. The nurse knows that the type of crisis Ms. ANA is experiencing is:

• A. Developmental crisis
• B. Maturational crisis
• C. Situational crisis
• D. Social Crisis

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

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