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A nurse is caring for a patient with diabetes who is newly diagnosed with diabetic nephropathy. The nurse should prioritize which of the following assessments?
- A. Kidney function tests.
- B. Blood pressure measurement.
- C. Blood glucose levels.
- D. Urine output monitoring.
Correct Answer: A
Rationale: The correct answer is A: Kidney function tests. In diabetic nephropathy, the kidneys are affected, leading to impaired kidney function. Monitoring kidney function tests such as serum creatinine and glomerular filtration rate is crucial to assess the progression of the disease and guide treatment. Blood pressure measurement (B) is important in managing diabetic nephropathy but does not directly assess kidney function. Blood glucose levels (C) are essential in managing diabetes overall but do not specifically address nephropathy. Urine output monitoring (D) is important for assessing kidney function but does not provide as comprehensive information as kidney function tests.
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When the nurse is assessing a patient for pain, what is the most appropriate action to take?
- A. Ask the patient to rate pain intensity
- B. Ask about any allergies
- C. Ask the patient to describe the pain
- D. Measure pain intensity using a scale
Correct Answer: A
Rationale: The correct answer is A because asking the patient to rate pain intensity using a scale (like 0-10) provides a standardized measure of pain perception. This quantitative data helps healthcare providers assess pain severity accurately and track changes over time. Asking about allergies (B) is important but not directly related to pain assessment. Asking the patient to describe the pain (C) provides qualitative information but may not be as reliable or consistent as a numerical rating. Measuring pain intensity using a scale (D) is similar to the correct answer but does not involve the patient's subjective input, which is crucial in pain assessment.
A patient is describing his symptoms to the nurse. Which of the following statements is a description of the setting of his symptoms?
- A. "It is a sharp, burning pain in my stomach."
- B. "I also have the sweats and nausea when I feel this pain."
- C. "I think this pain is telling me that something is wrong with me."
- D. "This pain happens every time I sit down to use the computer."
Correct Answer: D
Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.
Which of the following statements is a characteristic of the clinical practice guidelines for infants and children for a periodic health examination?
- A. They are used to diagnose an illness.
- B. They are helpful in identifying developmental delays in children.
- C. They recommend that every individual receive an annual physical examination.
- D. They list a frequency schedule for periodic health visits for a specific age group.
Correct Answer: D
Rationale: The correct answer is D because clinical practice guidelines for periodic health examinations provide a frequency schedule for health visits based on age. This is crucial for ensuring timely preventive care and monitoring of growth and development. Choice A is incorrect as guidelines focus on preventive care, not diagnosing illnesses. Choice B is incorrect because while guidelines may mention developmental milestones, their primary focus is on health maintenance. Choice C is incorrect as guidelines recommend health visits based on individual needs, not a one-size-fits-all annual physical examination.
What is the most appropriate intervention for a client with suspected peritonitis?
- A. Administer antibiotics
- B. Administer IV fluids
- C. Place the client in a supine position
- D. Administer epinephrine
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum typically caused by infection. Administering antibiotics is crucial to treat the underlying infection. IV fluids (B) may be necessary to maintain hydration, but antibiotics address the root cause. Placing the client in a supine position (C) is not a specific intervention for peritonitis. Administering epinephrine (D) is not indicated for peritonitis as it is not a treatment for infection.
What is the best method for a nurse to assess fluid balance in a client with kidney disease?
- A. Daily weight measurements
- B. Urine output monitoring
- C. Electrolyte panel monitoring
- D. Monitor vital signs
Correct Answer: B
Rationale: The correct answer is B: Urine output monitoring. This method is the best for assessing fluid balance in a client with kidney disease because the kidneys play a key role in regulating fluid balance by controlling urine production. Monitoring urine output provides direct insight into the body's fluid status and kidney function. Daily weight measurements (A) can be influenced by factors other than fluid balance. Electrolyte panel monitoring (C) assesses electrolyte levels, not fluid balance specifically. Monitoring vital signs (D) can give clues to fluid imbalance but is not as direct or specific as urine output monitoring.