Nursing Elites

1. Which nursing diagnosis is a priority for clients with Borderline personality disorder?

• A. Risk for injury
• B. Ineffective individual coping
• C. Altered thought process
• D. Sensory perceptual alteration

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.

2. A nurse is completing an admission assessment on an adolescent client who is vegan. Which breakfast item should the nurse recommend as a protein combination with their diet restriction?

• A. Bagel with cream cheese
• B. Wheat toast with jelly
• C. Oatmeal pancakes with peanut butter
• D. Eggs with tofu bacon

Correct answer: C

Rationale: The correct answer is C: Oatmeal pancakes with peanut butter. For a vegan client, it is important to recommend plant-based protein sources. Oatmeal pancakes with peanut butter offer a good protein combination that aligns with their dietary restriction. Choices A, B, and D are not suitable as they all contain animal-derived products, which are not suitable for a vegan diet.

3. Where in the body are microvilli located, facilitating the absorption of most nutrients?

• A. Stomach
• B. Pancreas
• C. Large Intestine
• D. Small Intestine

Correct answer: D

Rationale: The correct answer is D: Small Intestine. Microvilli are present in the small intestine, significantly increasing its surface area for efficient absorption of nutrients. The small intestine is the primary site for nutrient absorption in the body. The stomach (choice A) primarily functions to break down food with its acidic environment but is not where most nutrients are absorbed. The pancreas (choice B) produces enzymes to aid in digestion but does not directly absorb nutrients. The large intestine (choice C) mainly absorbs water and electrolytes from undigested food, rather than nutrients.

4. 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.

5. A client receiving total parenteral nutrition (TPN is awaiting the next container. What fluid should the nurse infuse in the interim?

• A. Dextrose 5% in water
• B. 0.9% sodium chloride
• C. Dextrose 10% in water
• D. Lactated Ringer's solution

Correct answer: B

Rationale: The correct answer is 0.9% sodium chloride. When a client receiving TPN is awaiting the next container, infusing 0.9% sodium chloride is the appropriate choice to maintain fluid and electrolyte balance. Dextrose solutions are not recommended as they do not provide sufficient nutrition. Lactated Ringer's solution contains electrolytes but lacks essential nutrients found in TPN, making it an inadequate choice during the delay in TPN delivery.

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