the nurse notes that the fall might also cause a possible head injury she will be observed for signs of increased intracranial pressure which include
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Nursing Elites

ATI RN

Nutrition ATI Test

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:

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 laboratory value would be considered a high-risk measure for coronary heart disease assessment?

Correct answer: B

Rationale: The correct answer is B: BMI > 31. A BMI over 31 is considered a high-risk factor for coronary heart disease as it indicates obesity, which is strongly linked to cardiovascular issues. Triglycerides > 150 mg/dL (choice A) can contribute to heart disease risk but are not as specific as BMI in assessing overall risk. LDL cholesterol < 128 mg/dL (choice C) is actually a desirable level, indicating lower risk. A blood pressure of 128/82 mmHg (choice D) is within normal range and not a high-risk measure specifically for coronary heart disease.

3. Which of the following is a normal finding during assessment of a Chest tube in a 3 way bottle system?

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

4. You are on morning duty in the medical ward. You have 10 patients assigned to you. During your endorsement rounds, you found out that one of your patients was not in bed. The patient next to him informed you that he went home without notifying the nurses. Which among the following will you do first?

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.

5. During the later stages of chronic kidney disease, what is the recommended protein intake in grams per kilogram of body weight per day?

Correct answer: A

Rationale: In the later stages of chronic kidney disease, the recommended protein intake is typically restricted to 0.6 to 0.75 grams per kilogram of body weight per day. This lower protein intake helps reduce the workload on the kidneys, as excessive protein can be challenging for the kidneys to process. Choice B (1.2 to 1.55) is incorrect as it suggests a higher protein intake, which is not recommended for individuals with advanced kidney disease. Choices C (1.0 to 1.2) and D (0.8 to 1.0) also advocate for protein intakes higher than what is typically advised for individuals in later stages of chronic kidney disease.

Similar Questions

Each of the following accurately describes features of MyPlate except one. Which one is the exception?
A client needs to increase his protein intake and enjoys certain foods. Which of the following foods should the nurse recommend as the best source of protein among these suggestions?
When can a patient's medical record become a potential issue for the doctor or nurse?
Clients may benefit from slightly higher fat intakes than are normally recommended if they have:
What is the absorbable unit of a protein?

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