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A nurse is caring for a patient with end-stage renal disease. The nurse should monitor the patient for which of the following?
- A. Hypertension.
- B. Hyperglycemia.
- C. Hypothyroidism.
- D. Hypokalemia.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. In end-stage renal disease, the kidneys are no longer able to regulate blood pressure effectively, leading to hypertension. This can increase the risk of cardiovascular complications. Monitoring for hypertension is crucial in these patients.
Rationale for why the other choices are incorrect:
B: Hyperglycemia is more commonly associated with diabetes rather than end-stage renal disease.
C: Hypothyroidism is a separate condition not directly related to end-stage renal disease.
D: Hypokalemia may occur in some cases of renal disease, but hypertension is a more common and critical concern in end-stage renal disease.
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A 45-year-old woman is at the clinic for a mental health assessment. When giving her the Four Unrelated Words Test, the nurse would be concerned if the patient:
- A. Could not give four unrelated words within 5 minutes.
- B. Could not give four unrelated words within 30 seconds.
- C. Could not recall four unrelated words after a 30-minute delay.
- D. Could not recall four unrelated words after a 60-minute delay.
Correct Answer: C
Rationale: The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall.
A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task.
B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue.
D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.
A nurse is teaching a patient with chronic kidney disease (CKD) about dietary modifications. Which of the following statements by the patient indicates proper understanding?
- A. I should limit my sodium intake and increase my potassium intake.
- B. I should avoid eating foods high in potassium.
- C. I can eat as much protein as I want.
- D. I should drink fluids freely without restriction.
Correct Answer: B
Rationale: Rationale:
B is correct because patients with CKD often have difficulty excreting potassium, so limiting high potassium foods is crucial to prevent hyperkalemia. A is incorrect because increasing potassium intake is not recommended. C is incorrect as excessive protein intake can worsen kidney function. D is incorrect because CKD patients typically have fluid restrictions to prevent fluid overload and electrolyte imbalances.
A nurse is caring for a patient who is post-operative following a knee replacement. Which of the following should the nurse prioritize in the post-operative care plan?
- A. Pain management.
- B. Encouraging early ambulation.
- C. Administering IV antibiotics.
- D. Monitoring for signs of deep vein thrombosis.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, improves circulation, aids in lung expansion, and promotes faster recovery. Pain management is important but encouraging mobility is a priority. Administering IV antibiotics is not necessary unless there is an infection present. Monitoring for signs of deep vein thrombosis is important but encouraging ambulation is a proactive approach to prevent its occurrence.
A patient describes an unreasonable, irrational fear of snakes. The feeling is so persistent that he can no longer even look at pictures of snakes without feeling uncomfortable. He has tried to identify all the places where he might encounter snakes and avoids them. The nurse recognizes that:
- A. He has a snake phobia.
- B. He is a hypochondriac. Snakes are usually harmless.
- C. He has an obsession. In this case, it is about snakes.
- D. He has a delusion that snakes are harmful. It must stem from an early traumatic incident involving snakes.
Correct Answer: A
Rationale: The correct answer is A: He has a snake phobia. Phobias are irrational and persistent fears of specific objects or situations. In this case, the patient's fear of snakes is unreasonable and causes discomfort even when encountering pictures of snakes. This aligns with the characteristics of a phobia.
Choice B is incorrect as hypochondriasis involves excessive worry about having a serious illness despite medical reassurance. Choice C is incorrect as obsessions are intrusive thoughts that cause anxiety, while the patient's fear of snakes is more of a specific fear rather than an obsession. Choice D is incorrect as delusions are fixed false beliefs, and the patient's fear of snakes is not based on a false belief but rather an irrational fear.
Which statement correctly exemplifies a critical cultural perspective?
- A. Culture is a relational aspect of people that shifts and changes over time.
- B. Culture assumes that people act in similar ways in all circumstances.
- C. Culture is most clearly reflected in a person's language and behaviour.
- D. Culture adapts to specific environmental factors and available natural resources.
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer (A):
1. A critical cultural perspective recognizes that culture is dynamic and contextual.
2. It acknowledges that culture is not static but evolves over time.
3. Understanding culture as relational highlights the interconnectedness of people and their environment.
4. This perspective emphasizes the importance of considering historical, social, and political factors in analyzing culture.
Summary of why other choices are incorrect:
B: This choice assumes cultural homogeneity, which does not account for diversity and variation within cultures.
C: While language and behavior are aspects of culture, they do not encompass the entirety of cultural expressions.
D: This choice oversimplifies culture by suggesting it is solely influenced by environmental factors, neglecting social and historical dimensions.