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 chronic pancreatitis is receiving discharge teaching from a nurse. Which of the following statements should the nurse make?

• A. "You should decrease your caloric intake when experiencing abdominal pain."?
• B. "You should increase your daily intake of protein."?
• C. "You should increase fat intake when experiencing loose stools."?
• D. "You should limit alcohol intake to 2-3 drinks per week."?

Correct answer: B

Rationale: In chronic pancreatitis, it is important to increase protein intake to support healing and prevent malnutrition. Choice A is incorrect because decreasing caloric intake during abdominal pain may lead to further nutritional deficiencies. Choice C is incorrect as increasing fat intake can exacerbate symptoms due to the impaired fat digestion in chronic pancreatitis. Choice D is incorrect as alcohol should be completely avoided in chronic pancreatitis to prevent further damage to the pancreas.

3. A client with a large lower-leg ulcer needs protein for wound healing. Which of the following foods should the nurse suggest?

• A. Kidney beans
• B. Grilled salmon
• C. Peanut butter
• D. Raw spinach

Correct answer: B

Rationale: Grilled salmon is the best choice for providing high-quality protein for wound healing. Salmon is rich in essential amino acids, omega-3 fatty acids, and vitamin D, which can help promote tissue repair and reduce inflammation. Kidney beans, peanut butter, and raw spinach are good protein sources but do not offer the same level of high-quality protein and nutrients needed specifically for wound healing.

4. The nurse is completing a nutritional assessment on a client. Which statement made by the client is most concerning to the nurse?

• A. "I notice when I take a vitamin E supplement, I bruise more easily."
• B. "I work nights and rarely go outside during the day."
• C. "I take warfarin, so I need to limit the amount of green leafy vegetables I eat."
• D. "My vitamin supplement has the recommended daily allowance of vitamin A."

Correct answer: A

Rationale: The correct answer is A. Excessive intake of vitamin E can increase the risk of bleeding as it acts as a blood thinner. Bruising easily may indicate too much vitamin E. Choice B is not as concerning as it describes a lifestyle that may lead to vitamin D deficiency due to lack of sunlight exposure. Choice C shows awareness of the interaction between warfarin and vitamin K, which is expected. Choice D indicates knowledge of the vitamin A content in the supplement, which is not a cause for concern.

5. A diet high in which nutrient can lead to increased risk of developing kidney stones?

• A. Fiber
• B. Protein
• C. Carbohydrates
• D. Unsaturated fats

Correct answer: B

Rationale: High protein intake can increase the risk of kidney stones due to elevated calcium excretion.

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