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A nurse is caring for a patient with a history of asthma. The nurse should monitor for which of the following complications?
- A. Pneumonia.
- B. Respiratory failure.
- C. Anemia.
- D. Hyperglycemia.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Asthma is a chronic respiratory condition that can lead to respiratory failure if not managed properly. The nurse should monitor for signs of worsening asthma symptoms such as increased respiratory rate, accessory muscle use, and decreased oxygen saturation. Pneumonia (A) is a possible complication but is not directly related to asthma. Anemia (C) and Hyperglycemia (D) are not typically associated with asthma and would not be the primary complications to monitor for in this case.
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The nurse is conducting a health interview with a patient named Salil. There is a language barrier, and no interpreter is available. Which of the following is the best example of an appropriate question for the nurse to ask in this situation?
- A. "Does Salil take medicine?"
- B. "Do you sterilize the bottles?"
- C. "Do you have nausea and vomiting?"
- D. "He has been taking his medicine, hasn't he?"
Correct Answer: A
Rationale: The correct answer is A: "Does Salil take medicine?" This is the best question because it is simple, direct, and focuses on gathering important medical information. It is clear and easy to understand even with a language barrier. Choice B is irrelevant and not related to the patient's health status. Choice C assumes symptoms without context. Choice D is inappropriate as it refers to the patient in the third person and includes a leading statement. Asking about medication directly is the most appropriate approach in this scenario.
A nurse is caring for a patient with a history of chronic kidney disease (CKD). The nurse should monitor for which of the following complications?
- A. Hyperkalemia.
- B. Hypokalemia.
- C. Hyperglycemia.
- D. Hypercalcemia.
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In CKD, kidneys struggle to excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac arrhythmias. Hypokalemia (B) is unlikely in CKD due to impaired potassium excretion. Hyperglycemia (C) is more commonly associated with diabetes rather than CKD. Hypercalcemia (D) is not a typical complication of CKD; instead, patients with CKD often experience low calcium levels.
The nurse is assessing a 75-year-old male patient. At the beginning of the mental status portion of the assessment, the nurse expects that this patient:
- A. Will have no decrease in any of his abilities, including response time.
- B. Will have difficulty on tests of remote memory because this typically decreases with age.
- C. May take a little longer to respond, but his general knowledge and abilities should not have declined.
- D. Will have had a decrease in his response time because of language loss and a decrease in general knowledge.
Correct Answer: C
Rationale: Rationale for Correct Answer C:
- As individuals age, it is normal to experience a slight decline in cognitive abilities, such as response time.
- However, general knowledge and abilities are usually well-preserved in older adults.
- It is expected that the 75-year-old patient may take a little longer to respond due to age-related changes but should not have a significant decline in general knowledge.
Summary of Incorrect Choices:
- Choice A is incorrect because it is unrealistic to expect no decrease in any abilities with age.
- Choice B is incorrect because while remote memory may decline with age, it is not a universal expectation for all older adults.
- Choice D is incorrect as it inaccurately attributes language loss and a decrease in general knowledge to all older adults.
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the:
- A. nursing diagnosis.
- B. medical diagnosis.
- C. admission diagnosis.
- D. collaborative diagnosis.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Nursing interventions are based on nursing diagnosis, which identifies patient's unique health needs.
2. Nursing diagnosis focuses on patient's response to health problems, not just medical conditions.
3. It guides nurses in planning individualized care to meet patient's specific needs.
4. Medical diagnosis (B) focuses on disease pathology, not holistic patient care.
5. Admission diagnosis (C) is a temporary identification of patient's primary reason for admission.
6. Collaborative diagnosis (D) involves joint identification of interprofessional health problems, not specific to nursing care.
Summary:
The correct answer is A because nursing interventions are tailored based on nursing diagnosis, which considers patient's responses to health issues. Medical diagnosis, admission diagnosis, and collaborative diagnosis do not provide the same level of individualized and holistic care planning as nursing diagnosis.
A nurse preparing to conduct a prenatal class is aware that which of the following groups is at highest risk for infant mortality?
- A. European Canadians
- B. Asian Canadians
- C. African Canadians
- D. First Nations people
Correct Answer: D
Rationale: The correct answer is D: First Nations people. First Nations people in Canada have historically faced systemic barriers to healthcare, leading to higher rates of infant mortality compared to other groups. This includes socio-economic factors, access to quality healthcare, and cultural differences impacting healthcare practices. European Canadians, Asian Canadians, and African Canadians do not face the same level of disparities and risk factors contributing to infant mortality rates as First Nations people. It is essential for healthcare providers to understand these disparities to address the health needs of First Nations communities effectively.