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. The nurse is caring for a client taking warfarin. Which meal brought in by the client's family is a priority to remove before the client eats it?

• A. Oriental cabbage salad with chicken
• B. Beef enchilada, rice, and beans
• C. Ham and cheese sandwich
• D. Macaroni salad and grapefruit slices

Correct answer: C

Rationale: The correct answer is C. Ham is high in vitamin K, which can interfere with warfarin. Vitamin K can decrease the effectiveness of warfarin, an anticoagulant medication. Choices A, B, and D do not contain high levels of vitamin K and are less likely to interfere with the client's warfarin therapy.

3. Which nutrient deficiency produces microcytic anemia, fatigue, faulty digestion, blue sclerae, pale conjunctivae, and tachycardia?

• A. Zinc
• B. Iron
• C. Sodium
• D. Potassium

Correct answer: B

Rationale: A deficiency in iron can lead to various symptoms, such as microcytic anemia, fatigue, faulty digestion, blue sclerae, pale conjunctivae, and tachycardia. Iron-deficiency anemia may be caused by inadequate dietary intake; accelerated demand or losses; and inadequate absorption secondary to diarrhea, decreased acid secretions, or antacid therapy. Iron deficiency is frequently the result of postnatal feeding practices and has a serious impact on growth and mental and psychomotor development in infants and children. Choices A, C, and D are incorrect as zinc deficiency typically presents with symptoms like impaired wound healing, taste abnormalities, and hair loss; sodium deficiency can lead to symptoms such as muscle cramps, dizziness, and confusion; and potassium deficiency may cause muscle weakness, fatigue, and abnormal heart rhythms.

4. Diet therapy for Rudy, who has acute renal failure is low-protein, low potassium and low sodium. The nutrition instructions should include:

• A. Recommend protein of high biologic value like eggs, poultry and lean meats
• B. Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes
• C. Allowing the client cheese, canned foods and other processed food
• D. Bananas, cantaloupe, orange and other fresh fruits can be included in the diet

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. A client was rushed in the E.R showing a whitish, leathery and painless burned area on his skin. The nurse is correct in classifying this burn as:

• A. First degree burn C. Third degree burn
• B. Second degree burn D. Partial thickness burn
• C.
• D.

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.

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