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A 32-year-old female patient complains that she has noticed several small, slightly raised, bright-red dots on her chest. On examination, the nurse thinks that the spots are probably:
- A. Anasarca.
- B. Scleroderma.
- C. Senile angiomas.
- D. Latent myeloma.
Correct Answer: C
Rationale: The correct answer is C: Senile angiomas. Senile angiomas are common benign growths of small blood vessels that appear as bright-red dots on the skin, commonly seen in older individuals. In this case, the patient is 32 years old, which is relatively young for an appearance of senile angiomas, but still within the possible age range. Anasarca (A) is generalized edema, not related to the described skin condition. Scleroderma (B) is a connective tissue disorder characterized by skin thickening and not associated with bright-red dots. Latent myeloma (D) is a type of bone marrow cancer and not related to the skin findings described.
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A patient with diabetes is experiencing a hypoglycemic episode. Which of the following is the nurse's first priority in this situation?
- A. Administering insulin.
- B. Providing a source of fast-acting carbohydrate.
- C. Checking the patient's blood glucose level.
- D. Contacting the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In a hypoglycemic episode, the priority is to raise the blood sugar quickly to prevent further complications. Fast-acting carbohydrates such as glucose tablets or orange juice can rapidly increase blood sugar levels. Administering insulin (choice A) can further lower blood sugar, checking blood glucose levels (choice C) may delay treatment, and contacting the healthcare provider (choice D) is not necessary in the immediate management of hypoglycemia.
A nurse is providing education to a patient with hypertension. Which of the following statements by the patient indicates the need for further education?
- A. I will limit my sodium intake.
- B. I will monitor my blood pressure regularly.
- C. I can stop taking my medication once my blood pressure is normal.
- D. I will exercise regularly to improve my health.
Correct Answer: C
Rationale: The correct answer is C. This statement indicates a misunderstanding because stopping medication once blood pressure is normal can lead to a relapse of hypertension. Step 1: Medication management is crucial for long-term control of hypertension. Step 2: Stopping medication abruptly can cause blood pressure to rise again. Step 3: Regular monitoring, limiting sodium intake, and exercising are all important aspects of hypertension management. Summary: Choices A, B, and D demonstrate good understanding of hypertension management, while choice C shows a need for further education on the importance of continued medication use.
A nurse is assessing a 45-year-old male patient with a history of smoking. The nurse would be most concerned if the patient reports:
- A. Shortness of breath with minimal exertion.
- B. Occasional cough with mucus production.
- C. Slight wheezing after physical activity.
- D. Experiencing no symptoms related to smoking.
Correct Answer: A
Rationale: The correct answer is A because shortness of breath with minimal exertion indicates possible respiratory distress, which can be a sign of significant lung damage from smoking. This symptom suggests a decreased ability to exchange oxygen and carbon dioxide efficiently, potentially leading to serious health complications.
Choice B is incorrect because an occasional cough with mucus production is common in smokers and may not be as alarming as shortness of breath.
Choice C is incorrect as slight wheezing after physical activity could be due to exercise-induced asthma rather than solely smoking-related issues.
Choice D is incorrect because even though the patient may not be experiencing symptoms related to smoking currently, it does not rule out potential underlying lung damage or future health risks associated with smoking.
Expert nurses learn to attend to a pattern of assessment data and act without consciously labelling it. This is referred to as:
- A. intuition.
- B. the nursing process.
- C. clinical knowledge.
- D. diagnostic reasoning.
Correct Answer: A
Rationale: The correct answer is A: intuition. Expert nurses develop intuition through years of experience, allowing them to recognize patterns in assessment data and act quickly without conscious labeling. This intuitive response is based on a deep understanding of situations and is often more efficient than consciously going through the nursing process. Clinical knowledge (C) is important but refers to theoretical understanding. The nursing process (B) involves systematic steps in patient care, not the automatic response seen in intuition. Diagnostic reasoning (D) involves a more deliberate thought process in identifying and treating health issues.
A 60-year-old woman is undergoing a mammogram. The nurse explains that the procedure is done to:
- A. Detect any abnormal growths or tumors in the breast tissue.
- B. Identify changes in hormone levels.
- C. Evaluate lung function related to breast cancer.
- D. Assess for signs of osteoporosis.
Correct Answer: A
Rationale: The correct answer is A because mammograms are specifically designed to detect abnormal growths or tumors in the breast tissue, particularly in the early stages of breast cancer. This is crucial for early detection and effective treatment.
Choice B is incorrect because mammograms are not used to identify changes in hormone levels. Choice C is incorrect because mammograms do not evaluate lung function related to breast cancer. Choice D is incorrect because mammograms do not assess for signs of osteoporosis; a bone density scan is typically used for that purpose.