Nokea
A nurse is caring for a patient with diabetes who is experiencing diabetic neuropathy. The nurse should educate the patient to prioritize which of the following?
- A. Inspecting feet daily for signs of injury.
- B. Exercising to increase circulation.
- C. Taking pain medication for relief.
- D. Increasing protein intake to support healing.
Correct Answer: A
Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial in diabetic neuropathy to prevent complications such as infections and ulcers. By inspecting the feet daily, the patient can identify any injuries early and seek prompt treatment. Exercising (choice B) is important, but not the top priority. Taking pain medication (choice C) only addresses symptoms, not the root cause. Increasing protein intake (choice D) may be beneficial for healing, but foot inspection is more directly related to preventing complications in diabetic neuropathy.
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What is the priority nursing action for a client with a suspected stroke?
- A. Administer oxygen
- B. Administer aspirin
- C. Administer thrombolytics
- D. Place the client in a supine position
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygenation is the priority in stroke management to ensure adequate oxygen supply to the brain. Oxygen therapy can help reduce hypoxia, which is crucial in the acute phase of a stroke. Administering aspirin (B) is important but comes after ensuring oxygenation. Administering thrombolytics (C) requires proper assessment and diagnostic confirmation, not an immediate priority. Placing the client in a supine position (D) may worsen stroke symptoms if there is compromised blood flow, so it is not recommended as the initial action.
Which condition is associated with inadequate intake of vitamin C?
- A. Rickets
- B. Marasmus
- C. Kwashiorkor
- D. Scurvy
Correct Answer: D
Rationale: The correct answer is D: Scurvy. Scurvy is caused by a deficiency in vitamin C, which is essential for collagen synthesis. Without enough vitamin C, collagen production is impaired, leading to symptoms like bleeding gums, fatigue, and joint pain.
Incorrect Choices:
A: Rickets is caused by a deficiency in vitamin D, not vitamin C.
B: Marasmus is a severe form of malnutrition due to inadequate intake of calories and protein, not specifically vitamin C.
C: Kwashiorkor is a form of severe acute malnutrition typically caused by inadequate protein intake, not vitamin C deficiency.
In summary, the correct answer is D (Scurvy) because it directly relates to inadequate intake of vitamin C, while the other choices are associated with different nutrient deficiencies.
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following interventions?
- A. Administering bronchodilators as prescribed.
- B. Encouraging the patient to avoid physical activity.
- C. Providing supplemental oxygen as needed.
- D. Monitoring for signs of acute kidney injury.
Correct Answer: A
Rationale: The correct answer is A: Administering bronchodilators as prescribed.
Rationale:
1. Bronchodilators help dilate the airways, improving airflow in COPD patients.
2. Priority is to address the underlying respiratory issue.
3. Bronchodilators are a standard treatment for managing COPD symptoms.
4. Improving airway patency is crucial in COPD exacerbations.
Summary:
- B: Encouraging avoidance of physical activity is incorrect as it can lead to deconditioning.
- C: Providing supplemental oxygen is important but not the priority in this case.
- D: Monitoring for acute kidney injury is unrelated to COPD management.
A nurse is assessing a patient who has a history of deep vein thrombosis (DVT). Which of the following findings would be most concerning?
- A. Pain and swelling in the leg.
- B. Redness and warmth around the affected area.
- C. Shortness of breath and chest pain.
- D. Pale skin and decreased pulse in the affected leg.
Correct Answer: C
Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function.
A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism.
B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism.
D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.
What is the most appropriate nursing action for a client with suspected peritonitis?
- A. Administer antibiotics
- B. Administer analgesics
- C. Apply an ice pack
- D. Perform a laparotomy
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum often caused by infection. Administering antibiotics is crucial to combat the infection. It is important to treat the underlying cause first before focusing on symptom management. Administering analgesics (B) may provide temporary relief but won't address the infection. Applying an ice pack (C) is not appropriate for peritonitis as it won't treat the infection. Performing a laparotomy (D) is a surgical procedure that may be necessary in severe cases but is not the initial nursing action.