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A nurse is caring for a patient with a history of hypertension and diabetes. The nurse should monitor for which of the following complications?
- A. Hyperglycemia.
- B. Stroke.
- C. Hypokalemia.
- D. Hypoglycemia.
Correct Answer: B
Rationale: Step 1: The patient has a history of hypertension and diabetes, putting them at risk for cardiovascular complications.
Step 2: Among the choices, stroke is a common complication associated with uncontrolled hypertension and diabetes.
Step 3: Monitoring for signs of stroke is crucial to prevent serious consequences in this patient population.
Step 4: Hyperglycemia (A) is a common complication of diabetes, but it is not directly related to the patient's hypertension.
Step 5: Hypokalemia (C) is an electrolyte imbalance that can occur in some conditions but is not as directly linked to the patient's history.
Step 6: Hypoglycemia (D) is a potential complication in diabetic patients but is not as common as hyperglycemia and is not directly related to hypertension.
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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 signs of an asthma exacerbation?
- A. Decreased work of breathing.
- B. Increased wheezing and shortness of breath.
- C. Improved oxygen saturation.
- D. Decreased sputum production.
Correct Answer: B
Rationale: The correct answer is B: Increased wheezing and shortness of breath. During an asthma exacerbation, bronchial airways become inflamed and narrowed, leading to increased wheezing and shortness of breath. This is a classic sign of worsening asthma. Other choices are incorrect because: A) Decreased work of breathing is not expected in an asthma exacerbation as the patient usually struggles to breathe. C) Improved oxygen saturation is unlikely as airway obstruction can lead to decreased oxygen levels. D) Decreased sputum production is not a typical sign of asthma exacerbation; in fact, increased sputum production may occur due to airway inflammation.
A female nurse is interviewing a male patient who is close in age to the nurse. During the interview, the patient makes an overtly sexual comment. The nurse's best response would be:
- A. Stop that immediately!
- B. Oh, you are too funny. Let's keep going with the interview.
- C. Do you really think I'd be interested?
- D. It makes me uncomfortable when you talk that way. Please don't.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the inappropriate behavior, sets a boundary, and communicates the nurse's discomfort in a professional manner. By stating that the comment makes them uncomfortable and asking the patient to refrain from such behavior, the nurse asserts their professionalism while maintaining respect for both parties. Choice A is too abrupt and may escalate the situation. Choice B dismisses the behavior, which is inappropriate. Choice C could be perceived as confrontational and potentially lead to a defensive response from the patient.
Which of the following is an example of a first-level priority problem?
- A. A patient with postoperative pain.
- B. A patient newly diagnosed with diabetes who needs teaching about diabetes.
- C. An individual with a small laceration on the sole of the foot.
- D. An individual with shortness of breath and respiratory distress.
Correct Answer: D
Rationale: The correct answer is D because shortness of breath and respiratory distress indicate a potentially life-threatening emergency requiring immediate intervention. This problem falls under the first-level priority as it addresses airway, breathing, and circulation, which are essential for survival. Choices A, B, and C are not first-level priorities as they do not pose an immediate threat to the patient's life or require urgent intervention. Postoperative pain, diabetes teaching, and a small foot laceration are important but can be addressed at a later time without immediate harm to the patient.
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.
A nurse is teaching a patient about managing hypertension. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood pressure regularly.
- B. I will take my medication as prescribed.
- C. I can stop taking my medication once my blood pressure is normal.
- D. I will decrease my sodium intake.
Correct Answer: C
Rationale: The correct answer is C. This statement indicates the need for further education because it suggests the patient plans to stop taking medication once blood pressure is normal, which can lead to hypertension returning. Monitoring blood pressure, taking medication as prescribed, and decreasing sodium intake are all appropriate actions for managing hypertension. Stopping medication abruptly can be dangerous and should only be done under a healthcare provider's guidance.