Nokea
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.
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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 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. Patients with diabetes are at risk for high blood sugar levels, leading to hyperglycemia. This can result in various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. The nurse should monitor the patient's blood glucose levels regularly to prevent these serious complications.
Explanation for incorrect choices:
A: Hypoglycemia - While hypoglycemia is a concern for diabetic patients, hyperglycemia is a more common and immediate risk.
B: Hyperkalemia - While hyperkalemia can occur in some diabetic patients, hyperglycemia is a more common and primary concern.
C: Hypotension - While diabetic patients can experience hypotension, hyperglycemia poses a more immediate threat to their health.
A nurse is caring for a patient with chronic kidney disease. The nurse should monitor for which of the following signs of fluid overload?
- A. Shortness of breath and weight gain.
- B. Increased urine output and fatigue.
- C. Dizziness and hypotension.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A, shortness of breath and weight gain, because fluid overload in patients with chronic kidney disease can lead to pulmonary edema and weight gain due to retained fluid. Shortness of breath occurs as the excess fluid accumulates in the lungs. Increased urine output and fatigue (B) are more indicative of dehydration. Dizziness and hypotension (C) are symptoms of hypovolemia, not fluid overload. Nausea and vomiting (D) are nonspecific symptoms and not typically associated with fluid overload.
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following interventions?
- A. Administering antibiotics as prescribed.
- B. Encouraging deep breathing and coughing exercises.
- C. Providing pain relief for chest discomfort.
- D. Monitoring oxygen saturation levels.
Correct Answer: B
Rationale: The correct answer is B because encouraging deep breathing and coughing exercises helps to improve lung function and prevent complications in pneumonia. This intervention can help clear secretions, improve oxygenation, and prevent respiratory distress. Administering antibiotics (choice A) is important but not the priority for immediate patient care. Providing pain relief (choice C) is essential but addressing respiratory function is more critical. Monitoring oxygen saturation levels (choice D) is necessary, but promoting lung function through exercises takes precedence.
Why is the concept of prevention essential in describing health?
- A. Disease can be prevented by treating the external environment.
- B. Most deaths among Canadians under age 65 are not preventable.
- C. Prevention places emphasis on the link between health and personal behaviour.
- D. The means to prevention is through treatment provided by primary health care practitioners.
Correct Answer: C
Rationale: The correct answer is C because prevention emphasizes the importance of personal behavior in maintaining health. It highlights the role of individual choices in preventing diseases and promoting well-being. A is incorrect because prevention focuses on proactive measures rather than treating external factors. B is incorrect as it contradicts the importance of prevention in reducing preventable deaths. D is incorrect because prevention is about avoiding health issues before they occur, not treating them after they have developed.