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A nurse is caring for a patient with a history of hypertension. The nurse should educate the patient to prioritize which of the following?
- A. Limiting sodium intake.
- B. Increasing potassium intake.
- C. Increasing fluid intake.
- D. Consuming more caffeine.
Correct Answer: A
Rationale: The correct answer is A: Limiting sodium intake. This is crucial for a patient with hypertension as excess sodium can lead to increased blood pressure. Sodium intake should be limited to lower the risk of cardiovascular complications.
B: Increasing potassium intake is beneficial, but not as critical as limiting sodium for hypertension management.
C: Increasing fluid intake may or may not be necessary depending on the patient's condition, but it is not as crucial as limiting sodium for hypertension management.
D: Consuming more caffeine can actually elevate blood pressure, so it is not recommended for patients with hypertension.
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A nurse is caring for a patient with chronic kidney disease. The nurse should monitor for which of the following signs of fluid overload?
- A. Shortness of breath and weight gain.
- B. Increased urine output and fatigue.
- C. Dizziness and hypotension.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A, shortness of breath and weight gain, because fluid overload in patients with chronic kidney disease can lead to pulmonary edema and weight gain due to retained fluid. Shortness of breath occurs as the excess fluid accumulates in the lungs. Increased urine output and fatigue (B) are more indicative of dehydration. Dizziness and hypotension (C) are symptoms of hypovolemia, not fluid overload. Nausea and vomiting (D) are nonspecific symptoms and not typically associated with fluid overload.
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. Which of the following is the best action for the nurse to take?
- A. Count the respirations, and call a physician immediately.
- B. Percuss the thorax bilaterally, noting any differences in percussion tones.
- C. Inspect the thorax for any masses and bleeding associated with respirations.
- D. Call for a chest x-ray examination, and wait for the results before beginning an assessment.
Correct Answer: B
Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This is the best action because it allows the nurse to assess for potential underlying issues such as pneumothorax or pleural effusion which could be causing the respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the chest.
Choice A is incorrect because simply counting respirations does not provide immediate information on the cause of distress. Choice C is incorrect as inspecting for masses and bleeding does not directly address the urgency of the situation. Choice D is incorrect as waiting for a chest x-ray would delay necessary interventions in a critical situation.
A nurse is teaching a patient with diabetes about blood glucose management. Which of the following statements by the patient indicates proper understanding?
- A. I should check my blood glucose levels regularly and adjust my insulin as needed.
- B. I can stop taking my insulin if my blood glucose is normal.
- C. I should skip meals if my blood sugar is high.
- D. I should only use my insulin when my blood sugar is over 200 mg/dL.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Regular blood glucose monitoring helps in understanding patterns and making informed decisions.
2. Adjusting insulin based on blood glucose levels is crucial for effective diabetes management.
3. This statement shows the patient's understanding of the need for personalized insulin adjustments.
4. It promotes self-management and proactive approach to blood sugar control.
Summary:
B: Stopping insulin abruptly can lead to dangerous complications.
C: Skipping meals can disrupt blood sugar levels and is not recommended.
D: Waiting for high blood sugar to use insulin can result in uncontrolled levels and complications.
A patient tells the nurse that she believes in "the hot"“cold theory, where illness is caused by hot or cold entering the body." Which of the following responses from the nurse would be most appropriate?
- A. I do not believe in this theory, but tell me about it.
- B. I know that this is your belief, but the cause is actually a virus.
- C. I did not take this in school, so it's unfamiliar to me.
- D. I have not heard of this theory. Tell me more.
Correct Answer: D
Rationale: The correct answer is D because it shows respect for the patient's belief and promotes open communication. By asking the patient to explain more about the hot-cold theory, the nurse acknowledges the patient's perspective and builds a trusting relationship. Option A dismisses the patient's belief, risking alienation. Option B is informative but misses the opportunity to understand the patient's cultural beliefs. Option C is unprofessional and does not address the patient's concerns.
To assess affect, the nurse should ask the patient:
- A. How do you feel today?
- B. Would you please repeat the following words?
- C. Have these medications had any effect on your pain?
- D. Has this pain affected your ability to dress yourself?
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Asking "How do you feel today?" directly addresses the patient's emotional state.
2. Assessing affect involves understanding the patient's emotional response or mood.
3. This open-ended question encourages the patient to express their feelings.
4. It allows the nurse to gain insight into the patient's emotional well-being.
5. Options B, C, and D focus on different aspects like memory, medication effectiveness, and functional ability, not directly related to assessing affect.