A patient is diagnosed with anemia. The nurse is educating the patient about dietary sources of iron. Which of the following foods is the best source of iron?
- A. Eggs.
- B. Spinach.
- C. Chicken liver.
- D. Oranges.
Correct Answer: C
Rationale: The correct answer is C: Chicken liver. Chicken liver is the best source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods like spinach or oranges. Eggs do contain iron, but in smaller amounts compared to chicken liver. Oranges, on the other hand, are a source of vitamin C which can enhance iron absorption but do not contain significant amounts of iron themselves.
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A patient with heart failure is experiencing shortness of breath, fatigue, and swelling in the legs. The nurse should monitor for signs of which of the following complications?
- A. Pulmonary embolism.
- B. Renal failure.
- C. Liver failure.
- D. Worsening heart failure.
Correct Answer: D
Rationale: The correct answer is D: Worsening heart failure. Shortness of breath, fatigue, and leg swelling are common symptoms of heart failure. Monitoring for signs of worsening heart failure, such as increased dyspnea, weight gain, and decreased exercise tolerance, is crucial. Pulmonary embolism (A) presents with sudden chest pain and shortness of breath, not typically associated with chronic heart failure. Renal failure (B) may present with decreased urine output and electrolyte imbalances. Liver failure (C) may present with jaundice and changes in mental status. However, given the symptoms presented by the patient, monitoring for worsening heart failure is the most appropriate choice.
Which of the following statements represents subjective data about the patient's skin?
- A. Skin dry in appearance
- B. No obvious lesions
- C. Denies colour change
- D. Lesion noted lateral aspect right arm
Correct Answer: C
Rationale: The correct answer is C because it indicates that the information was provided directly by the patient and is based on their perception or feeling. Subjective data is based on the patient's experiences and cannot be observed or measured by others. Choices A, B, and D are all objective data as they can be observed or measured by healthcare providers. Choice A describes a visible characteristic of the skin, choice B indicates absence of observable lesions, and choice D reports an observed lesion on a specific location of the skin. Therefore, choice C is the only option that reflects subjective data about the patient's skin.
A man has come in to the clinic because he is afraid he might have skin cancer. During the skin assessment, the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on' on his skin. Which of the following is the best prediction?
- A. He probably has senile lentigines, which do not become cancerous.
- B. He probably has actinic keratoses, precursors to basal cell carcinoma.
- C. He probably has acrochordons, precursors to squamous cell carcinoma.
- D. He probably has seborrheic keratosis, which do not become cancerous.
Correct Answer: D
Rationale: The correct answer is D: He probably has seborrheic keratosis, which do not become cancerous. Seborrheic keratosis typically appear as greasy, dark, and "stuck on" pigmented growths on the skin, commonly seen in older adults. They are benign and do not progress to skin cancer. This conclusion is based on the characteristics of seborrheic keratosis and the fact that they are not associated with malignancy.
Choice A (senile lentigines) is incorrect because although they are also common in older adults, they are flat and dark spots rather than raised growths. Choice B (actinic keratoses) is incorrect as they are precancerous lesions related to sun exposure, leading to a risk of developing squamous cell carcinoma, not basal cell carcinoma. Choice C (acrochordons) are skin tags and not precursors to squamous cell carcinoma.
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 diabetes about insulin administration. Which of the following statements by the patient indicates proper understanding?
- A. I will inject insulin into my arm to ensure faster absorption.
- B. I will rotate injection sites to avoid tissue damage.
- C. I should inject insulin only when my blood glucose is elevated.
- D. I should inject insulin into the same spot every time to ensure consistency.
Correct Answer: B
Rationale: The correct answer is B: I will rotate injection sites to avoid tissue damage. This statement indicates proper understanding because rotating injection sites helps prevent tissue damage and ensures consistent absorption. Injecting into the same spot every time can lead to lipohypertrophy. Injecting insulin only when blood glucose is elevated is incorrect as insulin is needed regularly. Injecting into the arm for faster absorption is also incorrect, as it can lead to unpredictable absorption rates. Rotation of sites is crucial for optimal insulin absorption and to prevent complications.
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