Nokea
A nurse is teaching a patient with diabetes about managing foot care. Which of the following statements by the patient indicates proper understanding?
- A. I will inspect my feet daily for cuts or blisters.
- B. I will avoid trimming my toenails to prevent injury.
- C. I will wear tight shoes to avoid blisters.
- D. I will ignore any small wounds on my feet.
Correct Answer: A
Rationale: The correct answer is A: "I will inspect my feet daily for cuts or blisters." This statement indicates proper understanding because daily foot inspection is crucial for early detection of any wounds, which can prevent complications in diabetic patients.
Incorrect choices:
B: Avoiding trimming toenails can lead to ingrown nails and potential injury.
C: Wearing tight shoes can increase the risk of blisters and discomfort.
D: Ignoring small wounds can lead to infections and more serious foot issues.
In summary, choice A is correct as it promotes proactive foot care, while the other choices can potentially harm the patient's foot health.
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A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions to prevent complications?
- A. Encouraging early ambulation and use of compression stockings.
- B. Administering pain medication regularly.
- C. Monitoring for signs of infection.
- D. Providing nutritional support and hydration.
Correct Answer: A
Rationale: The correct answer is A. Encouraging early ambulation and use of compression stockings is crucial post-abdominal surgery to prevent complications like deep vein thrombosis and pneumonia. Ambulation helps prevent blood clots and promotes lung expansion. Compression stockings aid in preventing blood pooling in the legs. Administering pain medication regularly (B) is important but not the priority. Monitoring for infection (C) is essential but not the priority immediately post-op. Providing nutritional support and hydration (D) is important but not as critical as preventing immediate complications.
A nurse is caring for a patient with chronic heart failure. Which of the following interventions should the nurse prioritize?
- A. Administering diuretics as prescribed.
- B. Encouraging increased fluid intake.
- C. Restricting sodium intake.
- D. Administering pain medications as needed.
Correct Answer: A
Rationale: The correct answer is A: Administering diuretics as prescribed. Diuretics help reduce fluid retention in patients with heart failure, relieving symptoms like edema and shortness of breath. Prioritizing diuretics can help manage the patient's fluid balance and improve heart function. Encouraging increased fluid intake (B) is contraindicated as it can worsen fluid overload. Restricting sodium intake (C) is important in heart failure management but not the top priority over administering diuretics. Administering pain medications (D) is not a priority intervention for chronic heart failure management.
Critical thinking in the expert nurse is greatly enhanced by opportunities to:
- A. apply theory in real situations.
- B. work with physicians to provide patient care.
- C. follow physician orders in providing patient care.
- D. develop nursing diagnoses for commonly occurring illnesses.
Correct Answer: A
Rationale: The correct answer is A because applying theory in real situations allows nurses to analyze, evaluate, and problem-solve effectively. This promotes critical thinking by integrating knowledge into practice. Working with physicians (B) and following orders (C) do not directly enhance critical thinking as they focus more on collaboration and task completion. Developing nursing diagnoses (D) is important but does not specifically target critical thinking skills like applying theory does.
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse would expect to find which of the following?
- A. Anasarca.
- B. Scleroderma.
- C. Pedal erythema.
- D. Clubbing of the nails.
Correct Answer: D
Rationale: The correct answer is D: Clubbing of the nails. Clubbing is a physical finding associated with chronic respiratory conditions like emphysema and bronchitis. It is characterized by the softening of the nail bed and the loss of the normal angle between the nail and the nail bed. This occurs due to chronic hypoxia and can be a sign of advanced lung disease. Anasarca (choice A) is generalized edema, not specific to respiratory conditions. Scleroderma (choice B) is a connective tissue disorder affecting the skin and other organs, not directly related to respiratory conditions. Pedal erythema (choice C) refers to redness of the feet and is not a typical finding in emphysema or bronchitis.
In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the:
- A. last glaucoma examination.
- B. frequency of breast self-examination.
- C. date of her last electrocardiogram.
- D. limitations related to her involvement in sports activities.
Correct Answer: D
Rationale: The correct answer is D because obtaining information on the limitations related to the girl's involvement in sports activities is crucial for assessing her overall physical health and well-being. This information helps in understanding any potential risks or issues that may arise from her participation in sports. Choices A, B, and C are incorrect as they are not relevant to a review of systems for a healthy 7-year-old girl. Glaucoma examination, breast self-examination frequency, and electrocardiogram date are not typically part of a routine review of systems for a child of her age and health status.