the nurse notes that the fall might also cause a possible head injury she will be observed for signs of increased intracranial pressure which include
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Nursing Elites

ATI RN

Nutrition ATI Test

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:

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 individual would be at the greatest risk for deficiencies in water-soluble vitamins?

Correct answer: An individual who consumes a diet high in processed foods.

Rationale: The correct answer is 'An individual who consumes a diet high in processed foods.' Processed foods are often deficient in water-soluble vitamins such as vitamin C and B vitamins, which can lead to deficiencies. On the other hand, fruits, vegetables, and organ meats are rich sources of these vitamins, so individuals who consume these regularly are less likely to develop deficiencies. While dairy products do contain some water-soluble vitamins, they are not depleted as quickly as they are in a diet high in processed foods, making a deficiency less likely.

3. A nurse is teaching a client who needs to increase their daily fluid intake. Which of the following foods has the highest percentage of water by weight?

Correct answer: C: Lettuce

Rationale: The correct answer is Lettuce. Lettuce has the highest percentage of water by weight among the options provided, making it an excellent choice to increase fluid intake. Yogurt and milk have some water content but are not as high in water percentage as lettuce. Honey, on the other hand, contains very little water and is not a good choice for increasing fluid intake.

4. What is the most likely complication for a client receiving TPN who suddenly develops tremors, dizziness, and diaphoresis?

Correct answer: D

Rationale: The correct answer is D, Hypoglycemia. When a client receiving TPN suddenly develops tremors, dizziness, and diaphoresis, it is indicative of hypoglycemia. TPN provides a high concentration of glucose, and if it is abruptly stopped or the infusion rate is reduced, it can lead to hypoglycemia. Choices A, B, and C are incorrect as they do not directly correlate with the symptoms described in the scenario. Fluid volume overload typically presents with edema and hypertension, sepsis with fever and increased heart rate, and hyperglycemia with polyuria, polydipsia, and blurred vision.

5. Sam is trying to lose weight by skipping lunch. By the middle of the afternoon, Sam is very uncomfortable and feels that they "have" to eat. Sam is experiencing:

Correct answer: D

Rationale: Hunger is the physiological need to eat, which Sam is experiencing due to skipping a meal and the body signaling the need for nutrients.

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