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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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A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?
- A. Pneumonia.
- B. Respiratory failure.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD have impaired lung function, making them at risk for respiratory failure due to inadequate oxygenation. This can occur due to exacerbation of COPD, infections, or other factors. Monitoring for signs of respiratory distress is crucial.
A: Pneumonia - While patients with COPD are at higher risk for pneumonia due to impaired lung function, respiratory failure is a more immediate and critical complication to monitor for in this scenario.
C: Hypoglycemia - COPD does not directly increase the risk of hypoglycemia, so monitoring for this complication is not a priority in this case.
D: Hypertension - Although some patients with COPD may have hypertension, it is not a common complication directly related to COPD. Monitoring for respiratory failure is more essential in this situation.
A nurse is teaching a patient with diabetes about self-management. Which of the following statements by the patient indicates proper understanding?
- A. I will monitor my blood glucose levels regularly.
- B. I will stop taking my insulin when my blood sugar is within normal range.
- C. I will eat a balanced diet and exercise regularly.
- D. I will avoid sugary foods to manage my blood sugar.
Correct Answer: A
Rationale: The correct answer is A because monitoring blood glucose levels regularly is essential for managing diabetes effectively. By monitoring blood glucose levels, the patient can make informed decisions about medication, diet, and exercise. This helps in preventing complications and maintaining blood sugar levels within the target range.
Choice B is incorrect because stopping insulin when blood sugar is within the normal range can lead to fluctuations and potential hyperglycemia. Choice C is a good practice but does not specifically address blood sugar management. Choice D is also important but does not encompass all aspects of diabetes management.
The review of systems provides the nurse with:
- A. physical findings related to each system.
- B. information regarding health promotion practices.
- C. an opportunity to teach the patient medical terms.
- D. information necessary for the nurse to diagnose the patient's medical problem.
Correct Answer: B
Rationale: Step 1: The review of systems is a systematic approach to assessing the patient's overall health.
Step 2: It gathers information about symptoms across different body systems.
Step 3: This information helps identify potential health risks and guide health promotion practices.
Step 4: Choice B is correct as it aligns with the purpose of the review of systems.
Summary:
- Choice A is incorrect because it focuses on physical findings only, not the comprehensive assessment.
- Choice C is incorrect as the review of systems is not primarily for teaching medical terms.
- Choice D is incorrect as it does not provide enough information for diagnosing specific medical problems.
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 nurse is caring for a patient with chronic kidney disease. The nurse should monitor for which of the following signs of fluid overload?
- A. Shortness of breath and weight gain.
- B. Increased urine output and fatigue.
- C. Dizziness and hypotension.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A, shortness of breath and weight gain, because fluid overload in patients with chronic kidney disease can lead to pulmonary edema and weight gain due to retained fluid. Shortness of breath occurs as the excess fluid accumulates in the lungs. Increased urine output and fatigue (B) are more indicative of dehydration. Dizziness and hypotension (C) are symptoms of hypovolemia, not fluid overload. Nausea and vomiting (D) are nonspecific symptoms and not typically associated with fluid overload.