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A nurse is caring for a patient with chronic liver disease. The nurse should monitor for which of the following complications?
- A. Jaundice.
- B. Anemia.
- C. Hyperglycemia.
- D. Hypoglycemia.
Correct Answer: A
Rationale: The correct answer is A: Jaundice. In chronic liver disease, the liver is unable to properly process bilirubin, leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. It is a common complication of liver disease and indicates impaired liver function. Anemia (choice B) may occur in liver disease, but it is not the primary complication. Hyperglycemia (choice C) and hypoglycemia (choice D) are more commonly associated with diabetes or pancreatic disorders, rather than chronic liver disease. Therefore, monitoring for jaundice is crucial in the care of a patient with chronic liver disease.
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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.
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following interventions?
- A. Administering antibiotics as prescribed.
- B. Encouraging deep breathing and coughing exercises.
- C. Providing pain relief for chest discomfort.
- D. Monitoring oxygen saturation levels.
Correct Answer: B
Rationale: The correct answer is B because encouraging deep breathing and coughing exercises helps to improve lung function and prevent complications in pneumonia. This intervention can help clear secretions, improve oxygenation, and prevent respiratory distress. Administering antibiotics (choice A) is important but not the priority for immediate patient care. Providing pain relief (choice C) is essential but addressing respiratory function is more critical. Monitoring oxygen saturation levels (choice D) is necessary, but promoting lung function through exercises takes precedence.
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.
The nurse is interviewing a recent immigrant from Mexico. During the course of the interview, the man leans forward and then finally moves his chair close enough that his knees are nearly touching the nurse's. The nurse begins to feel uncomfortable with his proximity. Which of the following statements describes the most appropriate response by the nurse?
- A. Try to relax; this behaviour is culturally appropriate for this person.
- B. Discreetly move the chair back to a more comfortable distance, and then continue with the interview.
- C. These behaviours are indicative of sexual aggression, and the nurse should confront this person about them.
- D. The nurse should laugh but tell him that he or she is uncomfortable with the proximity and ask the person to move away.
Correct Answer: A
Rationale: The correct answer is A: "Try to relax; this behavior is culturally appropriate for this person." In Mexican culture, close proximity during conversations is common and signifies engagement and trust. By understanding cultural differences, the nurse can avoid misinterpreting the behavior. Moving the chair back (choice B) may be seen as rude. Assuming sexual aggression (choice C) without evidence is inappropriate. Laughing and asking to move away (choice D) may embarrass the individual. Understanding and respecting cultural norms is crucial in providing effective care.
The review of systems provides the nurse with:
- A. physical findings related to each system.
- B. information regarding health promotion practices.
- C. an opportunity to teach the patient medical terms.
- D. information necessary for the nurse to diagnose the patient's medical problem.
Correct Answer: B
Rationale: Step 1: The review of systems is a systematic approach to assessing the patient's overall health.
Step 2: It gathers information about symptoms across different body systems.
Step 3: This information helps identify potential health risks and guide health promotion practices.
Step 4: Choice B is correct as it aligns with the purpose of the review of systems.
Summary:
- Choice A is incorrect because it focuses on physical findings only, not the comprehensive assessment.
- Choice C is incorrect as the review of systems is not primarily for teaching medical terms.
- Choice D is incorrect as it does not provide enough information for diagnosing specific medical problems.