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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.
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A nurse is caring for a patient with acute pancreatitis. The nurse should monitor for which of the following signs of complications?
- A. Decreased urine output and increased thirst.
- B. Increased blood pressure and heart rate.
- C. Hypotension and tachycardia.
- D. Tachypnea and cyanosis.
Correct Answer: C
Rationale: The correct answer is C: Hypotension and tachycardia. In acute pancreatitis, complications like hypovolemic shock can lead to hypotension and tachycardia due to fluid shifts and inflammation. Decreased urine output and increased thirst (A) may indicate dehydration but are not specific to pancreatitis. Increased blood pressure and heart rate (B) are not typical signs of complications in pancreatitis. Tachypnea and cyanosis (D) suggest respiratory distress, which is not a common complication of pancreatitis.
Which of the following is the best indicator of a patient's nutritional status?
- A. Patient's weight
- B. Serum albumin levels
- C. Patient's food preferences
- D. Number of meals consumed per day
Correct Answer: B
Rationale: The correct answer is B: Serum albumin levels. Serum albumin is a protein produced by the liver and is a key indicator of a patient's nutritional status. Low levels of serum albumin indicate malnutrition or protein deficiency. Monitoring serum albumin levels provides an objective measure of the patient's overall nutritional status.
Choice A (Patient's weight) can be influenced by factors other than nutrition, such as fluid retention or muscle mass. Choice C (Patient's food preferences) does not provide direct information on the patient's actual nutritional intake. Choice D (Number of meals consumed per day) does not account for the quality or quantity of nutrients consumed in those meals.
Which of the following statements is an example of flight of ideas?
- A. My stomach hurts. Hurts, spurts, burts.
- B. Kiss, wood, reading, ducks, onto, maybe.
- C. Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom.
- D. I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates a rapid succession of loosely associated thoughts, typical of flight of ideas. The statement transitions from discussing a pill to the color red, then red velvet, and finally to a baby's bottom. This rapid and disjointed flow of thoughts is characteristic of flight of ideas, a symptom commonly seen in manic episodes of bipolar disorder. Choices A, B, and D do not exhibit the same level of rapid and tangential thoughts as choice C, making them incorrect.
A nurse is teaching a patient with hypertension about lifestyle modifications. Which of the following statements by the patient indicates proper understanding?
- A. I will monitor my blood pressure regularly.
- B. I will take my medication as prescribed.
- C. I can stop taking my medication if my blood pressure is normal.
- D. I will limit my alcohol intake and reduce sodium intake.
Correct Answer: D
Rationale: The correct answer is D, as limiting alcohol and reducing sodium intake are crucial lifestyle modifications for managing hypertension. Alcohol can raise blood pressure, while excess sodium can increase fluid retention and elevate blood pressure. Monitoring blood pressure regularly (choice A) is important but alone does not indicate understanding of lifestyle modifications. Taking medication as prescribed (choice B) is essential but does not address lifestyle changes. Stopping medication if blood pressure is normal (choice C) is dangerous, as hypertension often requires ongoing treatment. In summary, choice D addresses key lifestyle modifications necessary for managing hypertension, while the other choices do not fully demonstrate understanding of proper management strategies.
A nurse is caring for a patient with a history of chronic liver disease. The nurse should monitor for which of the following complications?
- A. Anemia.
- B. Jaundice.
- C. Hypertension.
- D. Hypoglycemia.
Correct Answer: B
Rationale: The correct answer is B: Jaundice. In chronic liver disease, impaired liver function leads to the accumulation of bilirubin in the blood, causing jaundice. Jaundice is a common complication seen in patients with liver disease. Anemia (choice A) may occur in liver disease but is not as specific as jaundice. Hypertension (choice C) is not a direct complication of liver disease. Hypoglycemia (choice D) is more commonly associated with pancreatic disorders, not liver disease. Therefore, monitoring for jaundice is crucial in patients with chronic liver disease.