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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.
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A nurse is caring for a patient with diabetes. The nurse should monitor for which of the following complications?
- A. Hypoglycemia.
- B. Hyperkalemia.
- C. Hypotension.
- D. Hyperglycemia.
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. In diabetes, hyperglycemia occurs when blood sugar levels are too high. This can lead to various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. Monitoring for hyperglycemia is crucial to prevent these serious complications.
A: Hypoglycemia is low blood sugar and can also occur in diabetes, but it is not the primary complication to monitor for in this case.
B: Hyperkalemia is high potassium levels and is not a common complication of diabetes unless there are other underlying issues.
C: Hypotension is low blood pressure, which can be a complication of diabetes but is not as directly related to glucose management as hyperglycemia.
In summary, monitoring for hyperglycemia is essential in diabetes care to prevent serious complications associated with high blood sugar levels.
During the health assessment, the nurse notes that a patient is anxious and worried about upcoming surgery. What is the nurse's first priority in this situation?
- A. Assess the patient's emotional state and provide reassurance.
- B. Discuss the risks and benefits of the surgery in detail.
- C. Encourage the patient to relax and not focus on the surgery.
- D. Call the surgeon to inform them of the patient's anxiety.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's emotional state and provide reassurance. The first priority is to address the patient's anxiety and worry, as this can impact their overall well-being and ability to cope with the upcoming surgery. By assessing the emotional state, the nurse can understand the patient's concerns and provide appropriate support and reassurance. Discussing the risks and benefits (choice B) may be important but not the immediate priority. Encouraging relaxation (choice C) may not address the underlying anxiety. Calling the surgeon (choice D) is not necessary at this point as the nurse should first focus on the patient's emotional needs.
A nurse is caring for a patient with a history of hypertension and heart failure. The nurse should monitor for which of the following signs of worsening heart failure?
- A. Increased urine output and weight loss.
- B. Swelling in the legs and shortness of breath.
- C. Decreased blood pressure and dizziness.
- D. Fatigue and constipation.
Correct Answer: B
Rationale: The correct answer is B: Swelling in the legs and shortness of breath. In heart failure, fluid can build up in the body causing swelling, particularly in the legs. Shortness of breath is a common symptom due to fluid accumulation in the lungs. Increased urine output and weight loss (A) are not indicative of worsening heart failure as they suggest fluid loss. Decreased blood pressure and dizziness (C) can be seen in other conditions like dehydration. Fatigue and constipation (D) are not specific signs of heart failure worsening.
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 caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?
- A. Pulmonary embolism.
- B. Pneumothorax.
- C. Hypercapnia.
- D. Asthma attack.
Correct Answer: C
Rationale: The correct answer is C, hypercapnia. In COPD, impaired lung function leads to inadequate oxygen exchange, causing increased carbon dioxide levels in the blood (hypercapnia). This can result in respiratory acidosis and further exacerbate respiratory distress. Monitoring for hypercapnia is crucial in COPD management to prevent respiratory failure.
Incorrect choices:
A: Pulmonary embolism - While patients with COPD are at increased risk for blood clots, pulmonary embolism is not a direct complication of COPD.
B: Pneumothorax - Although individuals with COPD may develop pneumothorax due to weakened lung tissue, it is not a common complication.
D: Asthma attack - Asthma and COPD are distinct conditions with different pathophysiology. Asthma attacks are not a typical complication of COPD.