Nursing Elites

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

• A. Restlessness, confusion, irritability
• B. Severe headache and confusion
• C. Elevated blood pressure and bradycardia
• D. Bradycardia and altered pupil response

Correct answer: A

Rationale: The correct answer is A: Restlessness, confusion, irritability. These are early signs of increased intracranial pressure (IICP) and require prompt intervention. Restlessness, confusion, and irritability are indicative of the brain's attempt to compensate for the rising pressure. Choice B is incorrect because severe headache alone is not specific to IICP and can be present in various conditions. Choice C is incorrect because elevated blood pressure is not a common sign of IICP; instead, hypertension may be present in the compensatory stage. Choice D is incorrect as bradycardia and altered pupil response are signs of advanced IICP, not early signs. Monitoring and recognizing these early signs are crucial for timely intervention and preventing further complications.

2. A patient who received an enema reports abdominal cramping. What should the nurse do?

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

Correct answer: B

Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.

3. What is the correct response when a patient receiving an enema reports abdominal cramping?

• A. Lower the height of the enema container
• B. Stop the enema procedure
• C. Remove the enema tubing
• D. Continue the enema at a slower rate

Correct answer: A

Rationale: The correct response when a patient receiving an enema reports abdominal cramping is to lower the height of the enema container. Lowering the height reduces the flow rate, which can help relieve cramping. Stopping the procedure (choice B) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (choice C) is not the initial step to take when addressing abdominal cramping during an enema. Continuing the enema at a slower rate (choice D) might not be as effective as lowering the height of the container to alleviate cramping.

4. What should the nurse do when a patient experiences abdominal cramping during enema administration?

• A. Lower the height of the enema solution container
• B. Stop the procedure and remove the tubing
• C. Continue the enema at a slower rate
• D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. Lowering the height helps relieve cramping by slowing down the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is incorrect as it does not directly address the cramping issue. Choice C, continuing the enema at a slower rate, could potentially worsen the cramping by prolonging the discomfort. Choice D, increasing the flow of the enema solution, is also incorrect as it may intensify the cramping and cause more discomfort to the patient.

5. What dietary modifications are recommended for a patient with pre-dialysis kidney disease?

• A. Limit phosphorus intake to 700 mg/day
• B. Increase sodium intake to 3 g/day
• C. Restrict protein intake to 0.55-0.60 g/kg/day
• D. Eat three large meals per day

Correct answer: A

Rationale: The correct answer is A: Limit phosphorus intake to 700 mg/day. Patients with pre-dialysis kidney disease should limit phosphorus intake to prevent further kidney damage. Excessive phosphorus can lead to mineral and bone disorders. Choice B is incorrect because increasing sodium intake is not recommended in pre-dialysis kidney disease. Choice C is incorrect as protein restriction is a common recommendation in advanced kidney disease, not pre-dialysis. Choice D is incorrect as eating three large meals per day is not a specific dietary modification for pre-dialysis kidney disease.

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