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. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

• A. Lie on your left side.
• B. Lie on your right side.
• C. Increase your fluid intake.
• D. Decrease your fluid intake.

Correct answer: B

Rationale: After a liver biopsy, the nurse should instruct the client to lie on the right side. This position helps apply pressure to the biopsy site, promoting hemostasis and reducing the risk of bleeding. Lying on the left side may not provide adequate pressure to the site. Increasing fluid intake is generally beneficial to prevent dehydration and aid in the recovery process, whereas decreasing fluid intake could lead to dehydration and possible complications. Therefore, the correct instruction is to lie on the right side.

3. What is the initial nursing action for a patient with chest pain and acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Check the patient's urine output
• C. Check cardiac enzymes
• D. Obtain IV access

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority initial action for a patient with chest pain and acute coronary syndrome. Nitroglycerin helps vasodilate coronary arteries, improving blood flow to the heart muscle and reducing chest pain. Checking the patient's urine output (choice B) and cardiac enzymes (choice C) are important assessments but are not the first priority when managing acute chest pain. Obtaining IV access (choice D) is essential for administering medications and fluids, but administering sublingual nitroglycerin takes precedence in the initial management of chest pain in acute coronary syndrome.

4. The nurse misread a patient's glucose as 210 mg/dL instead of 120 mg/dL and administered the insulin dose for a reading over 200 mg/dL. What is the priority action?

• A. Administer glucose IV
• B. Monitor for hyperglycemia
• C. Monitor for hypoglycemia
• D. Document the incident

Correct answer: C

Rationale: The priority action is to monitor the patient for signs of hypoglycemia as the nurse administered excess insulin due to misreading the glucose level. Administering glucose IV (Choice A) is not the immediate priority when dealing with hypoglycemia. Monitoring for hyperglycemia (Choice B) is not the correct action as the insulin was administered for a higher glucose reading. Documenting the incident (Choice D) is important but not the priority when the patient's safety is at risk due to possible hypoglycemia.

5. What symptoms are associated with a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Sudden loss of consciousness
• C. Loss of motor function with nausea
• D. Severe headache and vomiting

Correct answer: A

Rationale: A thrombotic stroke presents with a gradual loss of function on one side of the body due to a clot blocking blood flow to the brain. This gradual onset distinguishes it from a hemorrhagic stroke with sudden symptoms like loss of consciousness (Choice B), and from other conditions like migraine, which may present with severe headache and vomiting (Choice D). Nausea (Choice C) is not typically a primary symptom associated with a thrombotic stroke.

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