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A nurse is caring for a patient with diabetes who is experiencing diabetic neuropathy. The nurse should prioritize which of the following interventions?
- A. Encouraging regular foot inspections.
- B. Providing additional protein to the diet.
- C. Encouraging weight loss to reduce joint stress.
- D. Administering pain medication for relief.
Correct Answer: A
Rationale: The correct answer is A: Encouraging regular foot inspections. This is the priority intervention because diabetic neuropathy can lead to decreased sensation in the feet, increasing the risk of injury or infection. Regular foot inspections can help detect any issues early and prevent complications.
Incorrect choices:
B: Providing additional protein to the diet - While nutrition is important for overall health, providing additional protein does not directly address the specific issue of diabetic neuropathy.
C: Encouraging weight loss to reduce joint stress - Weight loss may be beneficial for overall health, but it is not the priority intervention for diabetic neuropathy.
D: Administering pain medication for relief - Pain management is important, but addressing the root cause through regular foot inspections is more essential in preventing further complications.
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A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following assessments?
- A. Oxygen saturation levels.
- B. Pain levels.
- C. Bowel sounds.
- D. Level of consciousness.
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation levels. This assessment is crucial in pneumonia to ensure adequate oxygenation. Low oxygen levels can lead to respiratory distress. Pain levels (B) are important but not a priority over oxygenation. Bowel sounds (C) are not directly related to pneumonia. Level of consciousness (D) is also important but not as critical as ensuring proper oxygen levels for a patient with pneumonia. Oxygen saturation levels should be prioritized to prevent complications and ensure the patient's respiratory status is stable.
Which statement is correct regarding the development of one's culture?
- A. Culture is genetically determined on the basis of racial background.
- B. Culture is rooted in several distinctive and specific social elements.
- C. Culture is a nonspecific phenomenon and is adaptive, but unnecessary.
- D. Culture is biologically determined on the basis of physical characteristics.
Correct Answer: B
Rationale: The correct answer is B because culture is indeed rooted in specific social elements such as language, customs, traditions, beliefs, and values. These elements are passed down through generations within a particular society or group. Choice A is incorrect because culture is not genetically determined, but rather learned and acquired through socialization. Choice C is incorrect as culture plays a crucial role in shaping identities, behaviors, and interactions within a society. Choice D is incorrect as culture is not biologically determined, but rather socially constructed.
A nurse is teaching a patient with diabetes about foot care. Which of the following statements by the patient indicates proper understanding?
- A. I will inspect my feet daily for cuts or blisters.
- B. I will wear tight shoes to avoid blisters.
- C. I will avoid trimming my toenails to prevent injury.
- D. I will not worry about foot care unless I experience pain.
Correct Answer: A
Rationale: The correct answer is A because daily inspection helps identify issues early, preventing complications. B is incorrect as tight shoes can cause blisters. C is wrong as proper toenail trimming is essential. D is incorrect because prevention is key in diabetic foot care.
A nurse is caring for a patient with a history of hypertension and heart failure. The nurse should monitor for which of the following signs of worsening heart failure?
- A. Increased urine output and weight loss.
- B. Swelling in the legs and shortness of breath.
- C. Decreased blood pressure and dizziness.
- D. Fatigue and constipation.
Correct Answer: B
Rationale: The correct answer is B: Swelling in the legs and shortness of breath. In heart failure, fluid can build up in the body causing swelling, particularly in the legs. Shortness of breath is a common symptom due to fluid accumulation in the lungs. Increased urine output and weight loss (A) are not indicative of worsening heart failure as they suggest fluid loss. Decreased blood pressure and dizziness (C) can be seen in other conditions like dehydration. Fatigue and constipation (D) are not specific signs of heart failure worsening.
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
- A. Examine only the body areas related to the problem for which the patient is hospitalized, and then do a complete assessment after the problem has been resolved.
- B. Perform a mini-database by examining the body areas directly related to the problem for which the patient is hospitalized.
- C. Consider this a normal finding, and proceed with the abdominal assessment.
- D. Examine the entire body to determine if the problem is linked to something else.
Correct Answer: A
Rationale: The correct answer is A because when a patient is experiencing significant shortness of breath, the nurse should initially focus on assessing the areas directly related to the presenting problem to address the immediate issue. This approach allows for prompt intervention and treatment of the patient's acute condition. Once the patient's respiratory distress is managed, the nurse can then proceed with a complete assessment to identify any underlying or additional health issues. This stepwise approach ensures that the patient's urgent needs are met first before conducting a comprehensive assessment.
Choices B, C, and D are incorrect because:
B: Performing a mini-database by only examining body areas directly related to the problem may not provide a comprehensive understanding of the patient's condition and could overlook other potential health issues.
C: Dismissing significant shortness of breath as a normal finding and proceeding with an abdominal assessment is inappropriate and could delay necessary interventions for the respiratory distress.
D: Examining the entire body to determine if the problem is linked to something else is inefficient and