Nursing Elites

1. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider?

• A. Breath sounds
• B. Temperature
• C. Blood pressure
• D. Creatine kinase

Correct answer: A

Rationale: The correct answer is A: Breath sounds. When caring for a client with unstable angina, changes in breath sounds could indicate left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. Reporting any abnormalities in breath sounds promptly to the provider is crucial to prevent further complications. Choices B, C, and D are not directly related to the immediate management of unstable angina. Temperature, blood pressure, and creatine kinase levels are important parameters to monitor but are not the priority in this situation.

2. What dietary teaching should be provided to a patient with GERD?

• A. Avoid mint and pepper
• B. Consume liquids with meals
• C. Increase fluid intake with meals
• D. Eat large meals before bed

Correct answer: A

Rationale: The correct dietary teaching for a patient with GERD is to avoid mint and pepper. Mint and pepper can trigger reflux symptoms and increase gastric acid secretion, exacerbating GERD. Choices B and C are not recommended for patients with GERD as consuming liquids with meals and increasing fluid intake during meals can contribute to reflux by distending the stomach. Choice D, eating large meals before bed, can also worsen GERD symptoms by increasing pressure on the lower esophageal sphincter and promoting reflux.

3. What should the nurse do for a patient experiencing abdominal cramping during enema administration?

• A. Lower the height of the enema solution container
• B. Stop the procedure and remove the tubing
• C. Continue the enema at a slower rate
• D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. This action helps relieve the cramping by slowing down the flow of the solution. Choice B, stopping the procedure and removing the tubing, is incorrect as it is too drastic and may not address the cramping. Choice C, continuing the enema at a slower rate, may exacerbate the cramping if the flow rate is still too high. Choice D, increasing the flow of the enema solution, would worsen the cramping and is not the appropriate intervention.

4. A patient has been diagnosed with a thrombotic stroke. What are the expected manifestations?

• A. Gradual loss of function on one side of the body
• B. Sudden loss of consciousness
• C. Seizures and confusion
• D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' Thrombotic strokes lead to slow and progressive symptoms as a result of decreased blood flow to a specific area of the brain. Choices B, C, and D are incorrect because sudden loss of consciousness, seizures, confusion, and loss of sensation in the affected limb are not typical manifestations of a thrombotic stroke.

5. What are the manifestations of increased intracranial pressure (IICP)?

• A. Restlessness, confusion, irritability
• B. Severe nausea and vomiting
• C. Elevated blood pressure and bradycardia
• D. Decreased heart rate and altered pupil response

Correct answer: A

Rationale: The correct manifestations of increased intracranial pressure (IICP) include restlessness, confusion, and irritability. These symptoms are a result of the brain being under pressure inside the skull. Severe nausea and vomiting (Choice B) are more commonly associated with increased intracranial pressure in children. Elevated blood pressure and bradycardia (Choice C) are not typical manifestations of increased intracranial pressure; instead, hypertension and bradycardia may be seen in Cushing's reflex, which is a late sign of increased IICP. Decreased heart rate and altered pupil response (Choice D) are also not primary manifestations of increased intracranial pressure, although altered pupil response, like a non-reactive or dilated pupil, can be seen in some cases.

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