Nursing Elites

1. A client with a head injury is receiving mechanical ventilation. Which finding indicates to the nurse that the client may be experiencing increased intracranial pressure (ICP)?

• A. Widening pulse pressure
• B. Sudden drop in heart rate
• C. A decrease in urine output
• D. Elevated blood pressure and widening pulse pressure

Correct answer: D

Rationale: In a client with increased intracranial pressure (ICP), the body's compensatory mechanisms lead to an elevation in blood pressure and a widening pulse pressure. This occurs due to the body's attempt to maintain cerebral perfusion. Therefore, elevated blood pressure and widening pulse pressure are classic signs of increased ICP and necessitate immediate attention. Choices A, B, and C are incorrect because a widening pulse pressure, sudden drop in heart rate, or decreased urine output are not specific indicators of increased ICP.

2. The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. The infant was born two weeks after his due date and is described as a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?

• A. Has your son had any immunizations yet?
• B. Is your son sleepy and difficult to feed?
• C. Are you breastfeeding or bottle-feeding your son?
• D. Were any relatives born with birth defects?

Correct answer: B

Rationale: The correct answer is B. Excessive sleepiness and difficulty feeding can be signs of hypothyroidism in infants. Asking about the infant's sleepiness and feeding pattern is crucial in assessing for hypothyroidism. Choice A is incorrect because immunizations are not directly related to hypothyroidism. Choice C is about feeding method and not specific to hypothyroidism. Choice D is unrelated as it asks about relatives with birth defects, which does not directly assess the infant's condition.

3. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Lying flat with legs elevated
• C. Lying on the side with the head slightly raised
• D. Sitting up and tilting the head back

Correct answer: A

Rationale: The child with a nosebleed (epistaxis) should be placed in a sitting position, leaning forward, to prevent blood from flowing down the throat. This position helps to control the bleeding and prevents the child from swallowing blood, which can cause nausea or vomiting. Choice B is incorrect because elevating the legs is not recommended for nosebleeds. Choice C is incorrect because lying on the side with the head slightly raised is not the optimal position for managing a nosebleed. Choice D is incorrect because tilting the head back can lead to blood flowing down the throat and potentially cause aspiration.

4. A client with chronic kidney disease (CKD) is scheduled for a hemodialysis session. Which laboratory value should the nurse monitor closely?

• A. Serum potassium
• B. Serum creatinine
• C. Serum sodium
• D. Serum chloride

Correct answer: C

Rationale: The correct answer is C: Serum sodium. In a client with chronic kidney disease (CKD) scheduled for hemodialysis, monitoring serum sodium levels closely is essential. Hemodialysis can cause rapid shifts in sodium levels, leading to electrolyte imbalances. While serum potassium (choice A) is important to monitor in CKD, it is not the most crucial before hemodialysis. Serum creatinine (choice B) is an indicator of kidney function but is not the most immediate concern before hemodialysis. Serum chloride (choice D) is not typically the primary electrolyte of concern in CKD patients before hemodialysis.

5. A client with liver cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?

• A. Serum albumin of 3.0 g/dL
• B. Bilirubin of 3.0 mg/dL
• C. Ammonia level of 80 mcg/dL
• D. Prothrombin time of 18 seconds

Correct answer: C

Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.

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