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. After ileostomy, which of the following condition is NOT expected?

• A. Increased weight
• B. Irritation of skin around the stoma
• C. Liquid stool
• D. Establishment of regular bowel movement

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. Sucrose is a:

• A. monosaccharide
• B. disaccharide
• C. polysaccharide
• D. starch

Correct answer: B

Rationale: Sucrose is a disaccharide composed of one glucose and one fructose molecule.

4. Each of the following is a fat-soluble vitamin except for one. Which is the exception?

• A. Vitamin A
• B. Vitamin C
• C. Vitamin D
• D. Vitamin K

Correct answer: B

Rationale: The correct answer is B, Vitamin C. Vitamin C is a water-soluble vitamin, not fat-soluble. Fat-soluble vitamins are Vitamins A, D, E, and K. These vitamins are stored in the body's fat tissues and liver, unlike water-soluble vitamins which are not stored and are eliminated in urine, making them less likely to reach toxic levels.

5. 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.

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