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. Ms. Maria Salvacion says that she is the incarnation of the holy Virgin Mary. She said that she is the child of the covenant that would save this world from the evil forces of Satan. One morning, while caring for her, she stood in front of you and said “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” The best response by the Nurse is:

• A. Tell me more about being the Virgin Mary
• B. So, You are the Virgin Mary?
• C. Excuse me but, you are not anymore a Virgin so you cannot be the Blessed Virgin Mary.
• D. You are Maria Salvacion

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.

3. Which of the following is not correct?

• A. energy density is a comparison of energy (kcals) content to the weight of food
• B. if a food product contains a 15% daily value of calcium, that product is said to be a low source of calcium
• C. MyPlate illustrates the 5 food groups
• D.

Correct answer: B

Rationale: A product with 15% Daily Value (DV) of calcium is considered a good source, not a low source. Typically, anything 10-19% DV is considered a good source.

4. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers?

• A. Apply liberal amount of mineral oil to the area
• B. Use karaya paste and rings around the stoma
• C. Clean the area daily with soap and water before applying bag
• D. Apply talcum powder twice a day

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 nurse in a long-term care facility is developing strategies to promote increased food intake for an older adult client. Which of the following interventions should the nurse implement?

• A. Offer sugar substitutes to increase the client’s appetite.
• B. Provide opportunities to eat three large meals per day.
• C. Provide entertainment while the client is eating.
• D. Offer finger foods at mealtime.

Correct answer: D

Rationale: The correct intervention for promoting increased food intake for an older adult client is to offer finger foods at mealtime. Finger foods are easier for older adults to manage, making eating less cumbersome and more enjoyable, which can help increase overall food intake. Providing sugar substitutes (Choice A) may not necessarily increase appetite and could have negative health effects. Eating three large meals per day (Choice B) may be overwhelming and not suitable for older adults who may prefer smaller, more frequent meals. While providing entertainment (Choice C) during meals can be beneficial in some cases, it may not directly contribute to increased food intake as effectively as offering finger foods.

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