Nokea
A nurse is teaching a patient about managing hypertension. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood pressure regularly.
- B. I will take my medication as prescribed.
- C. I can stop taking my medication once my blood pressure is normal.
- D. I will decrease my sodium intake.
Correct Answer: C
Rationale: The correct answer is C. This statement indicates the need for further education because it suggests the patient plans to stop taking medication once blood pressure is normal, which can lead to hypertension returning. Monitoring blood pressure, taking medication as prescribed, and decreasing sodium intake are all appropriate actions for managing hypertension. Stopping medication abruptly can be dangerous and should only be done under a healthcare provider's guidance.
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Which of the following is an example of a first-level priority problem?
- A. A patient with postoperative pain.
- B. A patient newly diagnosed with diabetes who needs teaching about diabetes.
- C. An individual with a small laceration on the sole of the foot.
- D. An individual with shortness of breath and respiratory distress.
Correct Answer: D
Rationale: The correct answer is D because shortness of breath and respiratory distress indicate a potentially life-threatening emergency requiring immediate intervention. This problem falls under the first-level priority as it addresses airway, breathing, and circulation, which are essential for survival. Choices A, B, and C are not first-level priorities as they do not pose an immediate threat to the patient's life or require urgent intervention. Postoperative pain, diabetes teaching, and a small foot laceration are important but can be addressed at a later time without immediate harm to the patient.
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. Which of the following is the best action for the nurse to take?
- A. Count the respirations, and call a physician immediately.
- B. Percuss the thorax bilaterally, noting any differences in percussion tones.
- C. Inspect the thorax for any masses and bleeding associated with respirations.
- D. Call for a chest x-ray examination, and wait for the results before beginning an assessment.
Correct Answer: B
Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This is the best action because it allows the nurse to assess for potential underlying issues such as pneumothorax or pleural effusion which could be causing the respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the chest.
Choice A is incorrect because simply counting respirations does not provide immediate information on the cause of distress. Choice C is incorrect as inspecting for masses and bleeding does not directly address the urgency of the situation. Choice D is incorrect as waiting for a chest x-ray would delay necessary interventions in a critical situation.
A female nurse is interviewing a male patient who is close in age to the nurse. During the interview, the patient makes an overtly sexual comment. The nurse's best response would be:
- A. Stop that immediately!
- B. Oh, you are too funny. Let's keep going with the interview.
- C. Do you really think I'd be interested?
- D. It makes me uncomfortable when you talk that way. Please don't.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the inappropriate behavior, sets a boundary, and communicates the nurse's discomfort in a professional manner. By stating that the comment makes them uncomfortable and asking the patient to refrain from such behavior, the nurse asserts their professionalism while maintaining respect for both parties. Choice A is too abrupt and may escalate the situation. Choice B dismisses the behavior, which is inappropriate. Choice C could be perceived as confrontational and potentially lead to a defensive response from the patient.
A patient with diabetes is being discharged after a prolonged hospitalization. Which of the following should the nurse include in discharge instructions?
- A. The patient should check their blood glucose levels regularly.
- B. The patient should stop taking insulin once they feel better.
- C. The patient should exercise vigorously every day.
- D. The patient should avoid all carbohydrates.
Correct Answer: A
Rationale: The correct answer is A. Regularly checking blood glucose levels is crucial for diabetic patients to monitor their condition and adjust treatment as needed. This helps in managing blood sugar levels effectively and preventing complications.
Choice B is incorrect because stopping insulin abruptly can lead to dangerous fluctuations in blood sugar levels.
Choice C is incorrect because while exercise is important for diabetic patients, vigorous exercise every day may not be suitable for everyone and should be discussed with healthcare providers.
Choice D is incorrect as carbohydrates are an essential source of energy and nutrients for the body. Diabetic patients can still consume carbohydrates in controlled portions as part of a balanced diet.
A nurse is teaching a patient with diabetes about blood glucose management. Which of the following statements by the patient indicates proper understanding?
- A. I should check my blood glucose levels regularly and adjust my insulin as needed.
- B. I can stop taking my insulin if my blood glucose is normal.
- C. I should skip meals if my blood sugar is high.
- D. I should only use my insulin when my blood sugar is over 200 mg/dL.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Regular blood glucose monitoring helps in understanding patterns and making informed decisions.
2. Adjusting insulin based on blood glucose levels is crucial for effective diabetes management.
3. This statement shows the patient's understanding of the need for personalized insulin adjustments.
4. It promotes self-management and proactive approach to blood sugar control.
Summary:
B: Stopping insulin abruptly can lead to dangerous complications.
C: Skipping meals can disrupt blood sugar levels and is not recommended.
D: Waiting for high blood sugar to use insulin can result in uncontrolled levels and complications.