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A nurse is caring for a patient with a history of chronic liver disease. The nurse should monitor for which of the following complications?
- A. Anemia.
- B. Jaundice.
- C. Hypertension.
- D. Hypoglycemia.
Correct Answer: B
Rationale: The correct answer is B: Jaundice. In chronic liver disease, impaired liver function leads to the accumulation of bilirubin in the blood, causing jaundice. Jaundice is a common complication seen in patients with liver disease. Anemia (choice A) may occur in liver disease but is not as specific as jaundice. Hypertension (choice C) is not a direct complication of liver disease. Hypoglycemia (choice D) is more commonly associated with pancreatic disorders, not liver disease. Therefore, monitoring for jaundice is crucial in patients with chronic liver disease.
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A nurse is caring for a patient with diabetes who is experiencing diabetic neuropathy. The nurse should prioritize which of the following interventions?
- A. Encouraging regular foot inspections.
- B. Providing additional protein to the diet.
- C. Encouraging weight loss to reduce joint stress.
- D. Administering pain medication for relief.
Correct Answer: A
Rationale: The correct answer is A: Encouraging regular foot inspections. This is the priority intervention because diabetic neuropathy can lead to decreased sensation in the feet, increasing the risk of injury or infection. Regular foot inspections can help detect any issues early and prevent complications.
Incorrect choices:
B: Providing additional protein to the diet - While nutrition is important for overall health, providing additional protein does not directly address the specific issue of diabetic neuropathy.
C: Encouraging weight loss to reduce joint stress - Weight loss may be beneficial for overall health, but it is not the priority intervention for diabetic neuropathy.
D: Administering pain medication for relief - Pain management is important, but addressing the root cause through regular foot inspections is more essential in preventing further complications.
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.
Which of the following is the best indicator of a patient's nutritional status?
- A. Patient's weight
- B. Serum albumin levels
- C. Patient's food preferences
- D. Number of meals consumed per day
Correct Answer: B
Rationale: The correct answer is B: Serum albumin levels. Serum albumin is a protein produced by the liver and is a key indicator of a patient's nutritional status. Low levels of serum albumin indicate malnutrition or protein deficiency. Monitoring serum albumin levels provides an objective measure of the patient's overall nutritional status.
Choice A (Patient's weight) can be influenced by factors other than nutrition, such as fluid retention or muscle mass. Choice C (Patient's food preferences) does not provide direct information on the patient's actual nutritional intake. Choice D (Number of meals consumed per day) does not account for the quality or quantity of nutrients consumed in those meals.
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.
A nurse is teaching a patient with diabetes about insulin administration. Which of the following statements by the patient indicates proper understanding?
- A. I will inject insulin into my arm to ensure faster absorption.
- B. I will rotate injection sites to avoid tissue damage.
- C. I should inject insulin only when my blood glucose is elevated.
- D. I should inject insulin into the same spot every time to ensure consistency.
Correct Answer: B
Rationale: The correct answer is B: I will rotate injection sites to avoid tissue damage. This statement indicates proper understanding because rotating injection sites helps prevent tissue damage and ensures consistent absorption. Injecting into the same spot every time can lead to lipohypertrophy. Injecting insulin only when blood glucose is elevated is incorrect as insulin is needed regularly. Injecting into the arm for faster absorption is also incorrect, as it can lead to unpredictable absorption rates. Rotation of sites is crucial for optimal insulin absorption and to prevent complications.