Nursing Elites

1. What lab value should be monitored in a patient with HIV?

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

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 T-cell count below 180 cells/mm3 signifies severe immunosuppression and an increased risk of opportunistic infections. Serum albumin levels (choice B) are important for nutritional status assessment but not specific to HIV monitoring. Hemoglobin levels (choice C) are important for assessing anemia but do not directly reflect HIV disease progression. White blood cell count (choice D) is a general marker of inflammation and infection, but monitoring CD4 T-cell count is more specific and crucial in managing HIV.

2. What are the characteristics of a thrombotic stroke?

• A. Gradual onset over minutes to hours
• B. Numbness on one side of the body
• C. Associated with a loss of consciousness
• D. Associated with seizures and convulsions

Correct answer: A

Rationale: The correct answer is A. Thrombotic strokes typically have a gradual onset over minutes to hours as they result from a clot obstructing blood flow. Choice B, numbness on one side of the body, is more commonly associated with an ischemic stroke rather than specifically a thrombotic stroke. Choice C, loss of consciousness, is not a defining characteristic of a thrombotic stroke. Choice D, seizures and convulsions, are more commonly seen in hemorrhagic strokes rather than thrombotic strokes.

3. 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.

4. After a healthcare provider misreads a glucose level and administers insulin, what is the priority intervention?

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

Correct answer: A

Rationale: The correct answer is to monitor for hypoglycemia. Administering insulin based on a misread glucose level can lead to hypoglycemia. Monitoring for hypoglycemia is crucial as it is a potential adverse effect of the insulin administration. Administering glucose IV (Choice B) is not the priority as there is no indication of hypoglycemia yet. Documenting the incident (Choice C) is important but not the immediate priority over patient safety. Monitoring for hyperglycemia (Choice D) is not the priority after administering insulin in response to a misread glucose level.

5. A nurse is planning care for a patient diagnosed with diabetes insipidus. What should be included in the care plan?

• A. Monitor serum albumin levels
• B. Restrict protein intake to 0.55-0.60 g/kg/day
• C. Encourage the patient to increase fluid intake
• D. Teach the patient to avoid alcohol

Correct answer: A

Rationale: The correct answer is to monitor serum albumin levels. In patients with diabetes insipidus, monitoring serum albumin levels is essential to assess for dehydration and nutritional deficits. Choices B, C, and D are not directly related to managing diabetes insipidus. Restricting protein intake, encouraging fluid intake, and teaching the patient to avoid alcohol are interventions that may be relevant for other medical conditions but are not specific to addressing the needs of a patient with diabetes insipidus.

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