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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.
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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.
To which part of the assessment is information about who lives with a child, the method of disciplining, and support system related?
- A. Family history
- B. Review of systems
- C. Functional assessment
- D. Reason for seeking care
Correct Answer: C
Rationale: The correct answer is C: Functional assessment. This type of assessment focuses on understanding how an individual functions in their daily life. Information about who lives with a child, the method of disciplining, and support system directly relate to the child's functionality and overall well-being. Family history (A) typically refers to medical conditions in the family. Review of systems (B) involves examining different body systems for symptoms. Reason for seeking care (D) pertains to the specific reason why the child is seeking medical attention and does not encompass the broader aspects of the child's functioning.
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.
A pregnant woman states, "I just know labour will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labour." The nurse responds by stating, "Oh, don't worry about labour so much. I have been through it myself, and yes, it is painful, but there are many good medications to decrease the pain." Which of the following statements about this response is true?
- A. It was a nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman's fears.
- B. It was a therapeutic response. The nurse should have shared her own experience with the patient to make her feel better.
- C. It was a nontherapeutic response. The nurse is essentially giving the message to the woman that labour cannot be tolerated without medication.
- D. It was a therapeutic response. By providing false assurance, the nurse created a sense of security and opened the door for more discussion.
Correct Answer: B
Rationale: The correct answer is B because the nurse's response was therapeutic by sharing her own experience to empathize with the patient. This helps establish a connection and validate the patient's feelings. It shows understanding without dismissing the patient's concerns.
A is incorrect because the nurse did not provide false reassurance but offered a comforting perspective.
C is incorrect as the nurse did not imply that medication was necessary but rather highlighted its availability as an option.
D is incorrect since the response did not provide false assurance but rather shared personal experience to offer support.
A nurse is teaching a patient with diabetes about self-management. Which of the following statements by the patient indicates proper understanding?
- A. I will monitor my blood glucose levels regularly.
- B. I will stop taking my insulin when my blood sugar is within normal range.
- C. I will eat a balanced diet and exercise regularly.
- D. I will avoid sugary foods to manage my blood sugar.
Correct Answer: A
Rationale: The correct answer is A because monitoring blood glucose levels regularly is essential for managing diabetes effectively. By monitoring blood glucose levels, the patient can make informed decisions about medication, diet, and exercise. This helps in preventing complications and maintaining blood sugar levels within the target range.
Choice B is incorrect because stopping insulin when blood sugar is within the normal range can lead to fluctuations and potential hyperglycemia. Choice C is a good practice but does not specifically address blood sugar management. Choice D is also important but does not encompass all aspects of diabetes management.