Nursing Elites

1. What are the early signs of increased intracranial pressure (IICP)?

• A. Restlessness, irritability, and confusion
• B. Sudden onset of seizures
• C. Decreased heart rate and pupillary response
• D. Loss of consciousness

Correct answer: A

Rationale: The correct answer is A: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These signs indicate that the brain is starting to experience pressure, often due to conditions such as trauma, tumors, or hemorrhage. Sudden onset of seizures (choice B) is not typically an early sign of IICP but can occur later as the pressure increases. Decreased heart rate and pupillary response (choice C) are more indicative of late-stage IICP as the brainstem becomes compromised. Loss of consciousness (choice D) is a late sign of IICP when the pressure has significantly increased and is causing significant brain dysfunction.

2. What should be taught to a patient following cataract surgery?

• A. Avoid NSAIDs
• B. Wear dark glasses when outdoors
• C. Report green or yellow drainage immediately
• D. Itching is normal unless accompanied by pain and nausea

Correct answer: A

Rationale: The correct answer is to avoid NSAIDs after cataract surgery to reduce the risk of bleeding. Choice B, wearing dark glasses when outdoors, is generally recommended after cataract surgery to protect the eyes from bright sunlight, but it is not the most critical instruction. Choice C, reporting green or yellow drainage immediately, is important to monitor for signs of infection, but it is not specific to cataract surgery. Choice D, itching is normal unless accompanied by pain and nausea, is not the most crucial advice post-cataract surgery. Therefore, the key instruction is to avoid NSAIDs to minimize bleeding risk.

3. A patient reports abdominal cramping during an enema administration. What action should the nurse take?

• A. Increase the flow of the enema
• B. Lower the height of the enema solution container
• C. Stop the enema procedure
• D. Remove the enema tubing

Correct answer: B

Rationale: When a patient experiences abdominal cramping during an enema administration, the nurse should lower the height of the enema solution container. Lowering the container helps to relieve cramping by slowing the flow of the solution, making it more comfortable for the patient. Increasing the flow (Choice A) would exacerbate the cramping. Stopping the procedure (Choice C) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (Choice D) is not the initial action indicated for cramping; adjusting the height is the more appropriate intervention.

4. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

• A. Decreased deep tendon reflexes
• B. Positive Chvostek's sign
• C. Hyperactive bowel sounds
• D. Dry mucous membranes

Correct answer: A

Rationale: Corrected deep tendon reflexes occur with hyponatremia. Other manifestations of hyponatremia include headache, confusion, lethargy, fatigue, seizures, and muscle weakness. Positive Chvostek's sign is associated with hypocalcemia, hyperactive bowel sounds are not typically related to hyponatremia, and dry mucous membranes are more commonly seen with dehydration.

5. What are the priority lab values to monitor in a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. White blood cell count
• C. Hemoglobin levels
• D. Serum albumin levels

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it indicates the level of immunocompromise. A CD4 count below 180 cells/mm3 is considered severe immunocompromise and requires close monitoring and intervention. Choices B, C, and D are not the priority lab values to monitor in HIV patients. While white blood cell count, hemoglobin levels, and serum albumin levels can provide valuable information about the patient's health status, they are not as specific or indicative of HIV disease progression and management as the CD4 T-cell count.

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