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Which of the following is the best choice for an opening statement with a patient who is in distress?
- A. "Nancy, my name is Mrs. C."
- B. "Hello, Mrs. H., my name is Mrs. C. It sure is cold today!"
- C. "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
- D. "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
Correct Answer: D
Rationale: The correct answer is D because it directly acknowledges the patient's distress and sets the stage for gathering essential information. By stating the need to ask questions about what happened, it shows empathy and readiness to provide help. Choice A is too formal and lacks empathy. Choice B shifts the focus away from the patient's distress. Choice C is similar to D but lacks the crucial element of acknowledging the patient's emotional state. Thus, D is the best choice for an opening statement in this scenario.
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Which critical thinking skill helps the nurse recognize relationships among data?
- A. Validation.
- B. Clustering-related cues.
- C. Identifying gaps in data.
- D. Distinguishing relevant from irrelevant.
Correct Answer: B
Rationale: The correct answer is B: Clustering-related cues. This critical thinking skill helps the nurse recognize relationships among data by grouping related information together. This aids in identifying patterns, connections, and trends within the data, leading to a better understanding of the situation. Validation (A) involves confirming the accuracy of data, not necessarily recognizing relationships. Identifying gaps in data (C) focuses on missing information rather than relationships among existing data. Distinguishing relevant from irrelevant (D) is important but does not directly address recognizing relationships among data. In summary, clustering-related cues (B) is the most relevant skill for recognizing relationships among data in critical thinking.
A nurse is caring for a patient with hypertension. The nurse should educate the patient to monitor for which of the following complications?
- A. Severe headaches and blurred vision.
- B. Weight loss and fatigue.
- C. Increased appetite and tremors.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A: Severe headaches and blurred vision. These symptoms can indicate a hypertensive crisis, a severe complication of hypertension. Headaches and blurred vision are signs of potentially dangerous high blood pressure levels. Weight loss and fatigue (B), increased appetite and tremors (C), and nausea and vomiting (D) are not typical complications of hypertension and do not directly relate to the cardiovascular effects of high blood pressure. Monitoring for severe headaches and blurred vision is crucial for early detection and management of hypertensive crises.
A nurse is caring for a patient with end-stage renal disease. The nurse should monitor the patient for which of the following?
- A. Hypertension.
- B. Hyperglycemia.
- C. Hypothyroidism.
- D. Hypokalemia.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. In end-stage renal disease, the kidneys are no longer able to regulate blood pressure effectively, leading to hypertension. This can increase the risk of cardiovascular complications. Monitoring for hypertension is crucial in these patients.
Rationale for why the other choices are incorrect:
B: Hyperglycemia is more commonly associated with diabetes rather than end-stage renal disease.
C: Hypothyroidism is a separate condition not directly related to end-stage renal disease.
D: Hypokalemia may occur in some cases of renal disease, but hypertension is a more common and critical concern in end-stage renal disease.
A patient describes an unreasonable, irrational fear of snakes. The feeling is so persistent that he can no longer even look at pictures of snakes without feeling uncomfortable. He has tried to identify all the places where he might encounter snakes and avoids them. The nurse recognizes that:
- A. He has a snake phobia.
- B. He is a hypochondriac. Snakes are usually harmless.
- C. He has an obsession. In this case, it is about snakes.
- D. He has a delusion that snakes are harmful. It must stem from an early traumatic incident involving snakes.
Correct Answer: A
Rationale: The correct answer is A: He has a snake phobia. Phobias are irrational and persistent fears of specific objects or situations. In this case, the patient's fear of snakes is unreasonable and causes discomfort even when encountering pictures of snakes. This aligns with the characteristics of a phobia.
Choice B is incorrect as hypochondriasis involves excessive worry about having a serious illness despite medical reassurance. Choice C is incorrect as obsessions are intrusive thoughts that cause anxiety, while the patient's fear of snakes is more of a specific fear rather than an obsession. Choice D is incorrect as delusions are fixed false beliefs, and the patient's fear of snakes is not based on a false belief but rather an irrational fear.
A nurse is assessing a patient with a history of hypertension. Which of the following findings would be most concerning?
- A. A blood pressure reading of 160/100 mm Hg.
- B. A blood pressure reading of 130/85 mm Hg.
- C. A blood pressure reading of 140/90 mm Hg.
- D. A blood pressure reading of 120/80 mm Hg.
Correct Answer: A
Rationale: The correct answer is A. A blood pressure reading of 160/100 mm Hg is most concerning because it falls within the hypertensive crisis range, indicating severely elevated blood pressure that requires immediate medical attention to prevent complications like stroke or heart attack. Choices B, C, and D are within the prehypertension or mild hypertension ranges and are not as immediately concerning.