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. When documenting outcome of Richard’s treatment Mario should include the following in his recording EXCEPT:

• A. Color, amount and consistency of sputum
• B. Character of breath sounds and respiratory rate before and after procedure
• C. Amount of fluid intake of client before and after the procedure
• D. Significant changes in vital signs

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.

3. A client with cholecystitis is being taught about required dietary modifications. Which of the following foods is appropriate for the client's diet?

• A. Creamed chicken
• B. Roast turkey
• C. Ice cream
• D. Macaroni and cheese

Correct answer: B

Rationale: Roast turkey is the most appropriate choice for a client with cholecystitis. Foods that are high in fat content, like creamed chicken, ice cream, and macaroni and cheese, should be avoided in cholecystitis as they can exacerbate symptoms due to the reduced ability of the gallbladder to process fats. Roast turkey is a leaner option that is better tolerated by individuals with cholecystitis.

4. What is the name of the record that shows all medications and treatments provided on a repeated basis?

• A. Nursing Health History and Assessment Worksheet
• B. Discharge Summary
• C. Nursing Kardex
• D. Medicine and Treatment Record

Correct answer: D

Rationale: The 'Medicine and Treatment Record' is the document that maintains a comprehensive log of all medications and treatments provided on a routine basis. It does not refer to the 'Discharge Summary', which is a clinical report prepared by healthcare professionals at the end of a hospital stay or series of treatments. The 'Nursing Health History and Assessment Worksheet' is used to gather comprehensive data about the patient's health history and current health status, but it does not record ongoing treatment details. The 'Nursing Kardex' is a patient care information system used to quickly communicate patient needs, but it does not consistently record all medications and treatments provided.

5. Which dietary recommendation is most appropriate for a patient with gout?

• A. Increase protein intake
• B. Reduce carbohydrate intake
• C. Avoid purine-rich foods
• D. Increase calcium intake

Correct answer: C

Rationale: The most appropriate dietary recommendation for a patient with gout is to avoid purine-rich foods. Purine-rich foods such as red meat and shellfish can lead to increased uric acid levels in the body, triggering gout flare-ups. Increasing protein intake (Choice A) is not recommended as some high-protein foods are also high in purines. Reducing carbohydrate intake (Choice B) and increasing calcium intake (Choice D) are not directly related to managing gout symptoms.

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