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A nurse is caring for a patient with a history of diabetes. The nurse should monitor for which of the following complications?
- A. Hypoglycemia.
- B. Hyperkalemia.
- C. Hypotension.
- D. Hyperglycemia.
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels, leading to hyperglycemia. This can result in various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. The nurse should monitor the patient's blood glucose levels regularly to prevent these serious complications.
Explanation for incorrect choices:
A: Hypoglycemia - While hypoglycemia is a concern for diabetic patients, hyperglycemia is a more common and immediate risk.
B: Hyperkalemia - While hyperkalemia can occur in some diabetic patients, hyperglycemia is a more common and primary concern.
C: Hypotension - While diabetic patients can experience hypotension, hyperglycemia poses a more immediate threat to their health.
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A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?
- A. Pneumonia.
- B. Respiratory failure.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD have impaired lung function, making them at risk for respiratory failure due to inadequate oxygenation. This can occur due to exacerbation of COPD, infections, or other factors. Monitoring for signs of respiratory distress is crucial.
A: Pneumonia - While patients with COPD are at higher risk for pneumonia due to impaired lung function, respiratory failure is a more immediate and critical complication to monitor for in this scenario.
C: Hypoglycemia - COPD does not directly increase the risk of hypoglycemia, so monitoring for this complication is not a priority in this case.
D: Hypertension - Although some patients with COPD may have hypertension, it is not a common complication directly related to COPD. Monitoring for respiratory failure is more essential in this situation.
When performing a physical assessment, the first technique the nurse will use is:
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct Answer: B
Rationale: The correct answer is B: Inspection. This is because visual observation is typically the initial step in a physical assessment to gather information about the patient's overall appearance, skin color, posture, and any obvious abnormalities. Palpation (A) involves touching and feeling for abnormalities, which usually follows inspection. Percussion (C) is the technique of tapping on the body to assess underlying structures, and auscultation (D) is listening to sounds produced by the body, both of which typically come after inspection and palpation. Inspecting the patient first allows the nurse to establish a baseline before moving on to more detailed assessment techniques.
A patient often seems to have difficulty coming up with the right words. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up was so full that I decided to take the stairs.' The nurse will note on his chart that he is using or experiencing:
- A. Blocking.
- B. Neologism.
- C. Circumlocution.
- D. Circumstantiality.
Correct Answer: C
Rationale: The correct answer is C: Circumlocution. This patient is using circumlocution, which is a communication strategy where a person describes something in a roundabout way instead of using the specific word. In this case, the patient is describing an elevator as "the thing that you step into that goes up." This is a common feature of language difficulties seen in conditions like aphasia.
A: Blocking is when a person suddenly stops speaking in the middle of a sentence due to an inability to recall a word, which is not happening in this scenario.
B: Neologism is the creation of new words or phrases, which is not evident here.
D: Circumstantiality is a speech pattern where the person includes unnecessary details and goes off on tangents, which is not demonstrated in the patient's response.
A 35-year-old pregnant woman comes to the clinic for her monthly appointment. During assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be:
- A. Keratosis.
- B. Mitoasma.
- C. Linea nigra.
- D. Linea gravida.
Correct Answer: C
Rationale: The correct answer is C: Linea nigra. This is a common finding during pregnancy due to hormonal changes causing hyperpigmentation on the abdomen. The other choices are incorrect because keratosis refers to a skin condition characterized by rough, scaly patches; melasma is a condition causing dark patches on the skin, often due to hormonal changes; and linea gravida is not a recognized term in dermatology. Therefore, based on the context of the patient being pregnant and presenting with hyperpigmentation on her face, the most likely finding would be Linea nigra, a dark line that runs from the navel to the pubic bone during pregnancy.
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions?
- A. Administering antiemetics as needed.
- B. Encouraging early ambulation to prevent complications.
- C. Providing wound care and dressing changes.
- D. Monitoring for signs of infection.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation to prevent complications. Early ambulation after abdominal surgery helps prevent postoperative complications like deep vein thrombosis and pneumonia. It promotes circulation, aids in bowel function, and reduces the risk of atelectasis. Encouraging the patient to move also helps with pain management and overall recovery.
Choice A: Administering antiemetics as needed. While addressing nausea and vomiting is important, it is not the top priority in this case.
Choice C: Providing wound care and dressing changes. Wound care is crucial, but ensuring early ambulation takes precedence to prevent complications.
Choice D: Monitoring for signs of infection. While monitoring for infection is essential, promoting early ambulation is a proactive measure to prevent various complications and enhance recovery.