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A nurse is caring for a patient who has a history of hypertension and reports a new onset of headaches, nausea, and dizziness. The nurse should be most concerned about which of the following?
- A. Hypertensive crisis.
- B. Migraine headache.
- C. Benign positional vertigo.
- D. Tension headache.
Correct Answer: A
Rationale: The correct answer is A: Hypertensive crisis. The nurse should be most concerned about this option because the patient has a history of hypertension and is experiencing new onset symptoms such as headaches, nausea, and dizziness, which could indicate a sudden and severe increase in blood pressure. This condition, if left untreated, can lead to serious complications such as stroke or heart attack.
Summary:
- B: Migraine headache is unlikely as the symptoms described are not typical of a migraine.
- C: Benign positional vertigo is unlikely as it does not explain the presence of headaches and nausea.
- D: Tension headache is less concerning compared to hypertensive crisis, given the patient's history of hypertension and the severity of symptoms.
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A patient is experiencing dizziness, blurred vision, and nausea. The nurse should first assess the patient's:
- A. Electrolyte levels.
- B. Blood pressure.
- C. Blood glucose levels.
- D. Temperature and respiratory rate.
Correct Answer: B
Rationale: The correct answer is B, Blood pressure. Dizziness, blurred vision, and nausea can be symptoms of hypotension or hypertension. Assessing the patient's blood pressure first is crucial to determine if the symptoms are related to blood pressure fluctuations. Electrolyte levels (A) and blood glucose levels (C) may be assessed later but do not address the immediate concern. Temperature and respiratory rate (D) are important assessments but are not the priority in this scenario where cardiovascular status needs to be evaluated first.
The review of systems provides the nurse with:
- A. physical findings related to each system.
- B. information regarding health promotion practices.
- C. an opportunity to teach the patient medical terms.
- D. information necessary for the nurse to diagnose the patient's medical problem.
Correct Answer: B
Rationale: Step 1: The review of systems is a systematic approach to assessing the patient's overall health.
Step 2: It gathers information about symptoms across different body systems.
Step 3: This information helps identify potential health risks and guide health promotion practices.
Step 4: Choice B is correct as it aligns with the purpose of the review of systems.
Summary:
- Choice A is incorrect because it focuses on physical findings only, not the comprehensive assessment.
- Choice C is incorrect as the review of systems is not primarily for teaching medical terms.
- Choice D is incorrect as it does not provide enough information for diagnosing specific medical problems.
To which part of the assessment is information about who lives with a child, the method of disciplining, and support system related?
- A. Family history
- B. Review of systems
- C. Functional assessment
- D. Reason for seeking care
Correct Answer: C
Rationale: The correct answer is C: Functional assessment. This type of assessment focuses on understanding how an individual functions in their daily life. Information about who lives with a child, the method of disciplining, and support system directly relate to the child's functionality and overall well-being. Family history (A) typically refers to medical conditions in the family. Review of systems (B) involves examining different body systems for symptoms. Reason for seeking care (D) pertains to the specific reason why the child is seeking medical attention and does not encompass the broader aspects of the child's functioning.
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following interventions?
- A. Administering antibiotics as prescribed.
- B. Encouraging deep breathing and coughing exercises.
- C. Providing pain relief for chest discomfort.
- D. Monitoring oxygen saturation levels.
Correct Answer: B
Rationale: The correct answer is B because encouraging deep breathing and coughing exercises helps to improve lung function and prevent complications in pneumonia. This intervention can help clear secretions, improve oxygenation, and prevent respiratory distress. Administering antibiotics (choice A) is important but not the priority for immediate patient care. Providing pain relief (choice C) is essential but addressing respiratory function is more critical. Monitoring oxygen saturation levels (choice D) is necessary, but promoting lung function through exercises takes precedence.
A nurse is caring for a patient with chronic liver disease. The nurse should monitor for which of the following complications?
- A. Jaundice.
- B. Anemia.
- C. Hyperglycemia.
- D. Hypoglycemia.
Correct Answer: A
Rationale: The correct answer is A: Jaundice. In chronic liver disease, the liver is unable to properly process bilirubin, leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. It is a common complication of liver disease and indicates impaired liver function. Anemia (choice B) may occur in liver disease, but it is not the primary complication. Hyperglycemia (choice C) and hypoglycemia (choice D) are more commonly associated with diabetes or pancreatic disorders, rather than chronic liver disease. Therefore, monitoring for jaundice is crucial in the care of a patient with chronic liver disease.