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A patient is experiencing dizziness, blurred vision, and nausea. The nurse should first assess the patient's:
- A. Electrolyte levels.
- B. Blood pressure.
- C. Blood glucose levels.
- D. Temperature and respiratory rate.
Correct Answer: B
Rationale: The correct answer is B, Blood pressure. Dizziness, blurred vision, and nausea can be symptoms of hypotension or hypertension. Assessing the patient's blood pressure first is crucial to determine if the symptoms are related to blood pressure fluctuations. Electrolyte levels (A) and blood glucose levels (C) may be assessed later but do not address the immediate concern. Temperature and respiratory rate (D) are important assessments but are not the priority in this scenario where cardiovascular status needs to be evaluated first.
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When performing a physical assessment, the first technique the nurse will use is:
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct Answer: B
Rationale: The correct answer is B: Inspection. This is because visual observation is typically the initial step in a physical assessment to gather information about the patient's overall appearance, skin color, posture, and any obvious abnormalities. Palpation (A) involves touching and feeling for abnormalities, which usually follows inspection. Percussion (C) is the technique of tapping on the body to assess underlying structures, and auscultation (D) is listening to sounds produced by the body, both of which typically come after inspection and palpation. Inspecting the patient first allows the nurse to establish a baseline before moving on to more detailed assessment techniques.
A nurse is caring for a patient with a history of hypertension and diabetes. The nurse should monitor for which of the following complications?
- A. Hyperglycemia.
- B. Stroke.
- C. Hypokalemia.
- D. Hypoglycemia.
Correct Answer: B
Rationale: Step 1: The patient has a history of hypertension and diabetes, putting them at risk for cardiovascular complications.
Step 2: Among the choices, stroke is a common complication associated with uncontrolled hypertension and diabetes.
Step 3: Monitoring for signs of stroke is crucial to prevent serious consequences in this patient population.
Step 4: Hyperglycemia (A) is a common complication of diabetes, but it is not directly related to the patient's hypertension.
Step 5: Hypokalemia (C) is an electrolyte imbalance that can occur in some conditions but is not as directly linked to the patient's history.
Step 6: Hypoglycemia (D) is a potential complication in diabetic patients but is not as common as hyperglycemia and is not directly related to hypertension.
A nurse is caring for a patient with chronic liver disease. The nurse should monitor for which of the following complications?
- A. Jaundice.
- B. Anemia.
- C. Hyperglycemia.
- D. Hypoglycemia.
Correct Answer: A
Rationale: The correct answer is A: Jaundice. In chronic liver disease, the liver is unable to properly process bilirubin, leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. It is a common complication of liver disease and indicates impaired liver function. Anemia (choice B) may occur in liver disease, but it is not the primary complication. Hyperglycemia (choice C) and hypoglycemia (choice D) are more commonly associated with diabetes or pancreatic disorders, rather than chronic liver disease. Therefore, monitoring for jaundice is crucial in the care of a patient with chronic liver disease.
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 nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following to prevent complications?
- A. Encouraging early ambulation.
- B. Administering pain medication.
- C. Providing wound care and dressing changes.
- D. Monitoring for signs of infection.
Correct Answer: A
Rationale: Correct Answer: A - Encouraging early ambulation
Rationale:
1. Early ambulation helps prevent post-operative complications like blood clots and pneumonia.
2. Movement promotes circulation, aids in lung expansion, and prevents muscle atrophy.
3. It also supports bowel function and helps prevent constipation, a common post-operative issue.
4. Ambulation aids in overall recovery and reduces the risk of complications associated with prolonged immobility.
Other Choices:
B: Administering pain medication - Important for comfort but not the top priority for preventing complications.
C: Providing wound care and dressing changes - Necessary for wound healing but not the immediate priority to prevent complications.
D: Monitoring for signs of infection - Critical but not the primary intervention to prevent complications immediately post-op.