Nursing Elites

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

• A. Restlessness, confusion, irritability
• B. Severe nausea and vomiting
• C. Elevated blood pressure and bradycardia
• D. Decreased heart rate and altered pupil response

Correct answer: A

Rationale: The correct manifestations of increased intracranial pressure (IICP) include restlessness, confusion, and irritability. These symptoms are a result of the brain being under pressure inside the skull. Severe nausea and vomiting (Choice B) are more commonly associated with increased intracranial pressure in children. Elevated blood pressure and bradycardia (Choice C) are not typical manifestations of increased intracranial pressure; instead, hypertension and bradycardia may be seen in Cushing's reflex, which is a late sign of increased IICP. Decreased heart rate and altered pupil response (Choice D) are also not primary manifestations of increased intracranial pressure, although altered pupil response, like a non-reactive or dilated pupil, can be seen in some cases.

2. What are the expected changes on an ECG for a patient with hypokalemia?

• A. Flattened T waves
• B. Prominent U waves
• C. ST elevation
• D. Wide QRS complexes

Correct answer: A

Rationale: Flattened T waves are an early sign of hypokalemia on an ECG. Hypokalemia primarily manifests as flattened T waves on an ECG. While prominent U waves can be seen in hypokalemia, they are not as specific as flattened T waves. ST elevation is more commonly associated with conditions like myocardial infarction rather than hypokalemia. Wide QRS complexes are typically not a feature of hypokalemia on an ECG.

3. What is the priority lab value for monitoring a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. Serum albumin levels
• C. White blood cell count
• D. Hemoglobin 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 serves as a key indicator of immune function. A count below 180 cells/mm3 indicates severe immunocompromise and an increased risk of opportunistic infections. Choice B, serum albumin levels, though important for assessing nutritional status, is not the priority lab value for HIV monitoring. Choice C, white blood cell count, is a nonspecific measure of immune function and may not accurately reflect the status of the immune system in HIV patients. Choice D, hemoglobin levels, are essential for evaluating anemia but are not the primary lab value for monitoring HIV.

4. A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?

• A. Place several pillows behind the client's head
• B. Place the client in a Sim's position
• C. Keep the client's neck in a midline position
• D. Maintain flexion of the client's hips at a 90° angle

Correct answer: C

Rationale: Keeping the client's neck in a midline position is crucial for managing increased intracranial pressure. This position helps optimize blood flow and minimizes the risk of further increasing ICP. Placing several pillows behind the client's head (Choice A) may inadvertently elevate the head, potentially worsening ICP. Placing the client in a Sim's position (Choice B) or maintaining flexion of the client's hips at a 90° angle (Choice D) are not directly related to managing increased ICP.

5. A patient with GERD is being taught by a nurse. What should the patient avoid?

• A. Avoid mint and pepper
• B. Increase water intake during meals
• C. Eat frequent small meals
• D. Consume more spicy foods

Correct answer: A

Rationale: Patients with GERD should avoid mint and spicy foods as they can trigger reflux. Choice B ('Increase water intake during meals') is not recommended for GERD patients as it can worsen symptoms by distending the stomach. Choice C ('Eat frequent small meals') is beneficial for GERD patients to prevent excessive stomach distension. Choice D ('Consume more spicy foods') is incorrect as spicy foods can exacerbate GERD symptoms.

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