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A nurse is assessing a patient's hydration status. Which of the following findings would suggest dehydration?
- A. Increased urine output
- B. Decreased heart rate
- C. Dry mucous membranes
- D. Increased blood pressure
Correct Answer: C
Rationale: The correct answer is C: Dry mucous membranes. Dry mucous membranes are a common sign of dehydration as the body lacks adequate fluid. When a person is dehydrated, there is a decrease in saliva production, leading to dryness in the mouth and throat. This can be easily observed during a physical examination by looking at the patient's lips, tongue, and inside of the mouth. On the other hand, increased urine output (choice A) is a sign of adequate hydration, decreased heart rate (choice B) can be a normal response to dehydration but is not a consistent indicator, and increased blood pressure (choice D) is not typically associated with dehydration. Therefore, dry mucous membranes are the most reliable finding to suggest dehydration in a patient.
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A nurse is teaching a patient with hypertension about lifestyle modifications. Which of the following dietary changes should the nurse emphasize?
- A. Increase intake of foods high in sodium.
- B. Decrease intake of saturated fats.
- C. Increase intake of processed foods.
- D. Decrease intake of fiber.
Correct Answer: B
Rationale: The correct answer is B: Decrease intake of saturated fats. Saturated fats can raise cholesterol levels, leading to increased risk of heart disease and hypertension. Decreasing intake of saturated fats can help lower blood pressure.
Incorrect choices:
A: Increasing intake of foods high in sodium can worsen hypertension by increasing blood pressure.
C: Increasing intake of processed foods often leads to higher sodium and saturated fat intake, worsening hypertension.
D: Decreasing intake of fiber is not ideal as fiber helps in maintaining a healthy weight and managing blood pressure.
Which of the following is an example of a secondary prevention activity?
- A. Routine immunizations
- B. Health screenings such as mammograms
- C. Smoking cessation programs
- D. Health education on healthy eating
Correct Answer: B
Rationale: The correct answer is B, Health screenings such as mammograms, because secondary prevention focuses on early detection and treatment of diseases to prevent progression. Health screenings help identify conditions at early stages, allowing for timely intervention. Routine immunizations (A) are considered primary prevention as they prevent diseases from occurring. Smoking cessation programs (C) and health education on healthy eating (D) are examples of primary prevention, as they aim to prevent the development of diseases by promoting healthy behaviors.
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 nurse is teaching a patient with a new diagnosis of diabetes about managing blood glucose levels. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood glucose levels regularly.
- B. I should follow a healthy diet to manage my condition.
- C. I can stop taking my insulin when my blood sugar is normal.
- D. I will exercise regularly to improve my health.
Correct Answer: C
Rationale: The correct answer is C: "I can stop taking my insulin when my blood sugar is normal." This statement indicates a misunderstanding of diabetes management. Here's the rationale:
1. Insulin is a crucial medication for managing diabetes, and stopping it abruptly can lead to serious complications.
2. Blood sugar levels can fluctuate, so stopping insulin when levels are normal is not safe or effective.
3. Proper education should emphasize the importance of consistent insulin use as prescribed by healthcare providers.
4. Choices A, B, and D demonstrate good understanding of diabetes management by focusing on monitoring blood glucose levels, following a healthy diet, and exercising regularly.
The nurse is performing a review of systems on a 76-year-old patient. Which of the following statements is correct for this situation?
- A. The questions asked are identical for all ages.
- B. The interviewer will start incorporating different questions for patients 70 years of age and older.
- C. Additional questions are reflective of the normal effects of aging.
- D. At this age, a review of systems is not necessary; just focus on current problems.
Correct Answer: C
Rationale: Rationale: Choice C is correct as additional questions in a review of systems for a 76-year-old patient should address age-related changes. This allows for better assessment of potential health issues specific to older adults. Choice A is incorrect as questions may vary based on age. Choice B is incorrect as age alone does not dictate question changes. Choice D is incorrect as a review of systems is important at all ages for comprehensive patient assessment.