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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.
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To assess affect, the nurse should ask the patient:
- A. How do you feel today?
- B. Would you please repeat the following words?
- C. Have these medications had any effect on your pain?
- D. Has this pain affected your ability to dress yourself?
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Asking "How do you feel today?" directly addresses the patient's emotional state.
2. Assessing affect involves understanding the patient's emotional response or mood.
3. This open-ended question encourages the patient to express their feelings.
4. It allows the nurse to gain insight into the patient's emotional well-being.
5. Options B, C, and D focus on different aspects like memory, medication effectiveness, and functional ability, not directly related to assessing affect.
The nurse is interviewing a recent immigrant from Mexico. During the course of the interview, the man leans forward and then finally moves his chair close enough that his knees are nearly touching the nurse's. The nurse begins to feel uncomfortable with his proximity. Which of the following statements describes the most appropriate response by the nurse?
- A. Try to relax; this behaviour is culturally appropriate for this person.
- B. Discreetly move the chair back to a more comfortable distance, and then continue with the interview.
- C. These behaviours are indicative of sexual aggression, and the nurse should confront this person about them.
- D. The nurse should laugh but tell him that he or she is uncomfortable with the proximity and ask the person to move away.
Correct Answer: A
Rationale: The correct answer is A: "Try to relax; this behavior is culturally appropriate for this person." In Mexican culture, close proximity during conversations is common and signifies engagement and trust. By understanding cultural differences, the nurse can avoid misinterpreting the behavior. Moving the chair back (choice B) may be seen as rude. Assuming sexual aggression (choice C) without evidence is inappropriate. Laughing and asking to move away (choice D) may embarrass the individual. Understanding and respecting cultural norms is crucial in providing effective care.
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 nurse is planning health education for a 65-year-old woman who has had a cerebrovascular accident (stroke) and is aphasic. Which of the following is most important to use when assessing mental health in this situation?
- A. Please count back from 100 by sevens.
- B. I will name three items and ask you to repeat them in a few minutes.
- C. Please point to articles in the room and parts of the body as I name them.
- D. What would you do if you found a stamped, addressed envelope on the sidewalk?
Correct Answer: C
Rationale: The correct answer is C: Please point to articles in the room and parts of the body as I name them. This is the most important assessment for mental health in an aphasic patient post-stroke because it evaluates their comprehension, communication abilities, and cognitive function. Pointing to articles and body parts demonstrates understanding and ability to follow instructions, which are crucial aspects of mental health assessment in this context.
A: Please count back from 100 by sevens - This choice involves memory and mathematical abilities, which may not accurately assess mental health in an aphasic patient.
B: I will name three items and ask you to repeat them in a few minutes - This choice tests memory recall, which is not as relevant for assessing mental health in an aphasic patient post-stroke.
D: What would you do if you found a stamped, addressed envelope on the sidewalk? - This choice assesses problem-solving skills, which may not be the most appropriate indicator of mental health in an aphasic patient.
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.