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 is the most likely complication for a client receiving TPN who suddenly develops tremors, dizziness, and diaphoresis?

• A. Fluid volume overload
• B. Sepsis
• C. Hyperglycemia
• D. Hypoglycemia

Correct answer: D

Rationale: The correct answer is D, Hypoglycemia. When a client receiving TPN suddenly develops tremors, dizziness, and diaphoresis, it is indicative of hypoglycemia. TPN provides a high concentration of glucose, and if it is abruptly stopped or the infusion rate is reduced, it can lead to hypoglycemia. Choices A, B, and C are incorrect as they do not directly correlate with the symptoms described in the scenario. Fluid volume overload typically presents with edema and hypertension, sepsis with fever and increased heart rate, and hyperglycemia with polyuria, polydipsia, and blurred vision.

3. Which team member works with the client to evaluate the need for special feeding devices and then teaches the client how to use the device?

• A. dietitian
• B. speech-language pathologist
• C. dietetic technician
• D. occupational therapist

Correct answer: D

Rationale: An occupational therapist is the team member who works with the client to evaluate the need for special feeding devices and teaches the client how to use them. Occupational therapists specialize in helping individuals with physical or cognitive impairments to perform daily activities. In this scenario, the need for special feeding devices may be due to impaired motor function or disability, making the occupational therapist the correct choice. The other options, dietitian, speech-language pathologist, and dietetic technician, do not typically specialize in evaluating the need for feeding devices or teaching clients how to use them.

4. What is the form in which energy from excess intake of proteins, fats, alcohol, and carbohydrates is stored?

• A. Protein
• B. Fat
• C. Carbohydrates
• D. Alcohol

Correct answer: B

Rationale: When the body consumes more energy than it needs, the surplus is stored as fat, regardless of whether the energy source was proteins, fats, alcohol, or carbohydrates. This is why the correct answer is 'Fat'. Other choices are incorrect because, in excess intake situations, the body does not store surplus energy as proteins, carbohydrates, or alcohol.

5. What is the purpose of the cuff in a Tracheostomy tube?

• A. Separate the upper and lower airway
• B. Separate trachea from the esophagus
• C. Separate the larynx from the nasopharynx
• D. Secure the placement of the tube

Correct answer: B

Rationale: The purpose of the cuff in a Tracheostomy tube is to separate the trachea from the esophagus. The cuff helps prevent aspiration by creating a seal that separates the trachea from the esophagus, reducing the risk of food or fluids entering the lungs. Choices A, C, and D are incorrect because the cuff's primary function in a Tracheostomy tube is to prevent aspiration rather than separating the upper and lower airway, larynx from the nasopharynx, or securing the placement of the tube.

Similar Questions