Nokea
Expert nurses learn to attend to a pattern of assessment data and act without consciously labelling it. This is referred to as:
- A. intuition.
- B. the nursing process.
- C. clinical knowledge.
- D. diagnostic reasoning.
Correct Answer: A
Rationale: The correct answer is A: intuition. Expert nurses develop intuition through years of experience, allowing them to recognize patterns in assessment data and act quickly without conscious labeling. This intuitive response is based on a deep understanding of situations and is often more efficient than consciously going through the nursing process. Clinical knowledge (C) is important but refers to theoretical understanding. The nursing process (B) involves systematic steps in patient care, not the automatic response seen in intuition. Diagnostic reasoning (D) involves a more deliberate thought process in identifying and treating health issues.
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A 32-year-old female patient complains that she has noticed several small, slightly raised, bright-red dots on her chest. On examination, the nurse thinks that the spots are probably:
- A. Anasarca.
- B. Scleroderma.
- C. Senile angiomas.
- D. Latent myeloma.
Correct Answer: C
Rationale: The correct answer is C: Senile angiomas. Senile angiomas are common benign growths of small blood vessels that appear as bright-red dots on the skin, commonly seen in older individuals. In this case, the patient is 32 years old, which is relatively young for an appearance of senile angiomas, but still within the possible age range. Anasarca (A) is generalized edema, not related to the described skin condition. Scleroderma (B) is a connective tissue disorder characterized by skin thickening and not associated with bright-red dots. Latent myeloma (D) is a type of bone marrow cancer and not related to the skin findings described.
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse prioritize?
- A. Administering diuretics.
- B. Providing supplemental oxygen.
- C. Increasing fluid intake.
- D. Encouraging bed rest.
Correct Answer: B
Rationale: The correct answer is B: Providing supplemental oxygen. In COPD, patients often have difficulty breathing due to impaired lung function. Supplemental oxygen helps improve oxygenation and relieves respiratory distress. Prioritizing this intervention is crucial for managing COPD exacerbations and preventing complications. Administering diuretics (A) may be indicated for comorbid conditions like heart failure but is not a priority in managing COPD. Increasing fluid intake (C) may not directly address the patient's respiratory distress. Encouraging bed rest (D) may lead to deconditioning and worsen respiratory function in COPD patients.
A nurse is caring for a patient with chronic liver disease. The nurse should monitor for signs of which of the following complications?
- A. Jaundice.
- B. Hypoglycemia.
- C. Hyperglycemia.
- D. Anemia.
Correct Answer: A
Rationale: The correct answer is A: Jaundice. In chronic liver disease, impaired liver function can result in the accumulation of bilirubin leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial in assessing the progression of liver disease.
B: Hypoglycemia is not a common complication of chronic liver disease. Liver plays a role in glycogen storage and glucose production, so hypoglycemia is less likely.
C: Hyperglycemia is more commonly associated with conditions like diabetes rather than chronic liver disease. The liver's role in glucose regulation may be impaired, but hyperglycemia is not a typical complication.
D: Anemia is not directly related to liver disease, although it may occur as a secondary complication due to factors like decreased production of certain blood components. Monitoring for anemia is important, but jaundice is a more specific complication of chronic liver disease.
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for signs of which of the following complications?
- A. Hypoglycemia.
- B. Respiratory failure.
- C. Hyperkalemia.
- D. Anemia.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD are at risk for respiratory failure due to impaired gas exchange and respiratory muscle weakness. This can lead to hypoxia and hypercapnia. Monitoring for signs such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial.
Hypoglycemia (A) is not a common complication of COPD. Hyperkalemia (C) is less likely to occur in COPD unless the patient is on medications that can cause elevated potassium levels. Anemia (D) may be present in COPD due to chronic inflammation, but it is not a direct complication that requires monitoring for signs of respiratory failure.
A nurse is caring for a patient with hypertension. The nurse should educate the patient to avoid which of the following?
- A. Limiting caffeine intake.
- B. Consuming more fruits and vegetables.
- C. Increasing salt intake.
- D. Increasing physical activity.
Correct Answer: C
Rationale: The correct answer is C: Increasing salt intake. Salt intake can worsen hypertension by causing water retention and increasing blood pressure. Limiting caffeine intake (A) and increasing physical activity (D) are beneficial for managing hypertension. Consuming more fruits and vegetables (B) is also recommended as they are part of a healthy diet that can help lower blood pressure. Overall, educating the patient to avoid increasing salt intake is crucial in managing hypertension effectively.