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A nurse is caring for a patient with a history of chronic asthma. The nurse should prioritize monitoring for which of the following complications?
- A. Pneumothorax.
- B. Hyperglycemia.
- C. Respiratory failure.
- D. Chronic renal failure.
Correct Answer: C
Rationale: The correct answer is C: Respiratory failure. For a patient with chronic asthma, the priority complication to monitor for is respiratory failure as it can be life-threatening. Asthma is a chronic respiratory condition that can lead to severe bronchoconstriction and impaired gas exchange, potentially resulting in respiratory failure. Monitoring for signs such as increased respiratory rate, use of accessory muscles, decreased oxygen saturation, and altered mental status is crucial. Pneumothorax (A) is a possible complication but less common in chronic asthma. Hyperglycemia (B) and chronic renal failure (D) are not directly related to asthma and are not the primary complications to monitor for in this case.
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The nurse is obtaining the health history of an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?
- A. Obstetrical history
- B. Childhood illnesses
- C. General health for the past 20 years
- D. Current health promotion activities
Correct Answer: D
Rationale: Rationale:
1. Current health promotion activities are important to assess the patient's preventive measures.
2. At 87 years old, focusing on current habits can help identify areas for improvement.
3. Obstetrical history is irrelevant as the patient is postmenopausal.
4. Childhood illnesses are less relevant compared to current health status.
5. General health for the past 20 years may not reflect current health behaviors.
Which statement is correct regarding the development of one's culture?
- A. Culture is genetically determined on the basis of racial background.
- B. Culture is rooted in several distinctive and specific social elements.
- C. Culture is a nonspecific phenomenon and is adaptive, but unnecessary.
- D. Culture is biologically determined on the basis of physical characteristics.
Correct Answer: B
Rationale: The correct answer is B because culture is indeed rooted in specific social elements such as language, customs, traditions, beliefs, and values. These elements are passed down through generations within a particular society or group. Choice A is incorrect because culture is not genetically determined, but rather learned and acquired through socialization. Choice C is incorrect as culture plays a crucial role in shaping identities, behaviors, and interactions within a society. Choice D is incorrect as culture is not biologically determined, but rather socially constructed.
A nurse is teaching a patient with hypertension about lifestyle modifications. Which of the following statements by the patient indicates proper understanding?
- A. I will monitor my blood pressure regularly.
- B. I will take my medication as prescribed.
- C. I can stop taking my medication if my blood pressure is normal.
- D. I will limit my alcohol intake and reduce sodium intake.
Correct Answer: D
Rationale: The correct answer is D, as limiting alcohol and reducing sodium intake are crucial lifestyle modifications for managing hypertension. Alcohol can raise blood pressure, while excess sodium can increase fluid retention and elevate blood pressure. Monitoring blood pressure regularly (choice A) is important but alone does not indicate understanding of lifestyle modifications. Taking medication as prescribed (choice B) is essential but does not address lifestyle changes. Stopping medication if blood pressure is normal (choice C) is dangerous, as hypertension often requires ongoing treatment. In summary, choice D addresses key lifestyle modifications necessary for managing hypertension, while the other choices do not fully demonstrate understanding of proper management strategies.
A nurse is teaching a patient with diabetes about insulin administration. Which of the following actions should the nurse emphasize to the patient?
- A. Store insulin at room temperature to prevent crystallization.
- B. Use insulin immediately after drawing it up into the syringe.
- C. Inject insulin into the same spot to avoid tissue damage.
- D. Rotate injection sites to prevent lipodystrophy.
Correct Answer: D
Rationale: The correct answer is D: Rotate injection sites to prevent lipodystrophy. Rotating injection sites helps prevent the development of lipodystrophy, a condition characterized by the loss of fat tissue at the injection site. This is important for maintaining consistent insulin absorption and reducing the risk of injection site complications.
A: Storing insulin at room temperature is generally recommended, but it is not the most critical action for insulin administration.
B: Using insulin immediately after drawing it up is not necessary for all types of insulin and may not be feasible in all situations.
C: Injecting insulin into the same spot can lead to tissue damage and inconsistent insulin absorption, so it should be avoided.
The inspection phase of the physical assessment:
- A. Yields little information
- B. Takes time and reveals a surprising amount of information
- C. Requires a quick glance at the patient's body systems
- D. May be somewhat uncomfortable for the expert practitioner
Correct Answer: B
Rationale: The correct answer is B because the inspection phase of a physical assessment involves visually examining the patient's body, which can reveal a surprising amount of information. This step is crucial in identifying visible abnormalities, such as skin discoloration, swelling, or asymmetry. It helps in assessing the patient's overall appearance, posture, and body movements. This detailed observation can provide valuable insights into the patient's health status and aid in making an accurate diagnosis.
Choice A is incorrect because the inspection phase actually provides significant information. Choice C is incorrect as it downplays the importance of thorough observation. Choice D is incorrect because the discomfort level for the expert practitioner is not a defining factor in the inspection phase.