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. Nurse Edna thinks that the patient is somewhat like his father. She then identifies positive feeling for the patient that affects the objectivity of her nursing care. This emotional reaction is called:

• A. Transference
• B. Counter Transference
• C. Reaction formation
• D. Sympathy

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. A factor contributing to the risk for dehydration in the older adult is that _____.

• A. drinking fluids causes loss of bladder control
• B. older adults do not seem to notice mouth dryness as readily as younger people
• C. increased fluid intake will decrease the intake of nutrient-dense foods
• D. changes in intestinal motility contribute to excess fluid loss

Correct answer: C

Rationale: Older adults may not notice mouth dryness as readily as younger individuals, increasing their risk for dehydration, especially if they do not consciously increase fluid intake.

4. A nurse is providing nutritional information to a client with osteoporosis. Which food should the nurse recommend as being the highest in calcium?

• A. 1 cup carrot strips
• B. 3 oz canned salmon
• C. 1 plain baked potato
• D. 1 cup chopped chicken breast

Correct answer: B

Rationale: Canned salmon with bones is high in calcium.

5. What percentage of body weight as fat does a woman with a healthy body composition typically average?

• A. 5%
• B. 15%
• C. 25%
• D. 35%

Correct answer: C

Rationale: A healthy body fat percentage for women typically ranges between 21% and 33%, with 25% being an average healthy body fat percentage. Choice A (5%) is too low for a healthy body fat percentage and is more in line with essential body fat levels. Choice B (15%) is also lower than the typical range for a healthy body fat percentage. Choice D (35%) is too high and would be considered high body fat for women.

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