Nursing Elites

1. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:

• A. perfusion
• B. locomotion
• C. respiration
• D. mentation

Correct answer: D

Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.

2. A client receiving continuous enteral tube feeding reports cramping and abdominal distention. Which of the following actions should the nurse take?

• A. Check for gastric residual.
• B. Apply low intermittent suction.
• C. Increase the rate of the feeding.
• D. Request a higher-fat formula.

Correct answer: A

Rationale: When a client on continuous enteral tube feeding experiences cramping and abdominal distention, the nurse should check for gastric residual. This assessment helps determine if the client is tolerating the feeding well or if there is a potential issue such as feeding intolerance. Applying low intermittent suction, increasing the feeding rate, or requesting a higher-fat formula are not appropriate actions for addressing the reported symptoms and may exacerbate the client's discomfort or lead to further complications.

3. Which step of the management process is concerned with Policy making and Stating the goals and objective of the institution?

• A. Planning
• B. Organizing
• C. Directing
• D. Controlling

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. 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. Loss of smell results in a condition that limits the capacity to detect the flavor of food and beverages, called:

• A. hypergeusia
• B. dysgeusia
• C. anosmia
• D. phantom taste

Correct answer: C

Rationale: The correct answer is C: anosmia. Anosmia refers to the loss of smell, which significantly affects the ability to detect flavors. Hypergeusia and dysgeusia, choices A and B, refer to heightened or distorted taste, respectively. 'Phantom taste' in choice D is not the correct term for the condition described in the question.

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