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. Which of the following provides greater flexibility, better balance, more endurance, and overall better health and greater longevity for older adults?

• A. Eating balanced meals
• B. Not smoking or drinking alcohol
• C. Daily physical activity
• D. Increased intake of calcium and iron

Correct answer: C

Rationale: The correct answer is C: Daily physical activity. Daily physical activity contributes to better flexibility, balance, endurance, and overall health, helping older adults maintain independence and reduce the risk of chronic diseases. Choices A, B, and D, although important for overall health, do not specifically address the benefits of greater flexibility, better balance, more endurance, and greater longevity associated with daily physical activity.

3. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:

• A. Increase the irrigating solution flow rate when abdominal cramps is felt
• B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
• C. Position client in semi-Fowler
• D. Hang the solution 18 inches above the stoma

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.

4. Theresa, a mother with a 2-year-old daughter, asks, 'At what age can I start taking my daughter's blood pressure as a routine procedure, since hypertension is common in our family?' What would your answer be?

• A. At 2 years old, you may
• B. As early as 1 year old
• C. When she's 3 years old
• D. When she's 6 years old

Correct answer: D

Rationale: Regular blood pressure checks generally start from age 3, but in the case of a family history of hypertension, they should start when the child is around 6 years old. This is because the readings will be more reliable and indicative of the child's health condition at this age. The other options are incorrect because they suggest earlier ages for routine blood pressure checks. While blood pressure can be measured at any age, it is not typically included as part of a routine health check-up for very young children unless there are specific health concerns.

5. As a nurse, you can help improve the effectiveness of communication among healthcare givers by:

• A. Use of reminders of ‘what to do’
• B. Using standardized list of abbreviations, acronyms, and symbols
• C. One-on-one oral endorsement
• D. Text messaging and e-mail

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

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