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What is the best method for a nurse to assess fluid balance in a client with kidney disease?
- A. Daily weight measurements
- B. Urine output monitoring
- C. Electrolyte panel monitoring
- D. Monitor vital signs
Correct Answer: B
Rationale: The correct answer is B: Urine output monitoring. This method is the best for assessing fluid balance in a client with kidney disease because the kidneys play a key role in regulating fluid balance by controlling urine production. Monitoring urine output provides direct insight into the body's fluid status and kidney function. Daily weight measurements (A) can be influenced by factors other than fluid balance. Electrolyte panel monitoring (C) assesses electrolyte levels, not fluid balance specifically. Monitoring vital signs (D) can give clues to fluid imbalance but is not as direct or specific as urine output monitoring.
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Which condition is characterized by writhing, twisting movements of the face and limbs?
- A. epilepsy
- B. Parkinson's
- C. muscular sclerosis
- D. Huntington's chorea
Correct Answer: D
Rationale: The correct answer is D: Huntington's chorea. Huntington's chorea is a genetic disorder characterized by involuntary, writhing, and twisting movements of the face and limbs, known as chorea. This is due to degeneration of certain brain cells. Epilepsy (A) involves seizures, not specific movements. Parkinson's (B) is characterized by tremors and rigidity, not chorea. Multiple sclerosis (C) affects the central nervous system, causing a variety of symptoms, but not typically chorea.
A nurse is teaching a patient with a history of stroke about preventing future strokes. Which of the following statements by the patient indicates the need for further education?
- A. I will take my blood pressure medication regularly.
- B. I will limit my alcohol consumption.
- C. I can stop taking my medication once my blood pressure is normal.
- D. I will maintain a healthy diet and exercise regularly.
Correct Answer: C
Rationale: The correct answer is C because stopping medication once blood pressure is normal can lead to a rebound increase in blood pressure, increasing the risk of stroke. A patient with a history of stroke needs to continue taking medications as prescribed to maintain optimal blood pressure control. Statements A, B, and D are all indicative of good stroke prevention strategies, such as managing blood pressure, limiting alcohol intake, and maintaining a healthy lifestyle.
A nurse is providing education to a patient with chronic kidney disease. Which of the following dietary recommendations should the nurse prioritize?
- A. Increase protein intake.
- B. Increase potassium intake.
- C. Limit phosphorus and potassium intake.
- D. Decrease fluid intake.
Correct Answer: C
Rationale: The correct answer is C: Limit phosphorus and potassium intake. Patients with chronic kidney disease often have difficulty excreting phosphorus and potassium, leading to potential complications. Limiting phosphorus and potassium intake can help prevent further kidney damage and maintain electrolyte balance. Prioritizing this dietary recommendation is crucial for managing the progression of the disease.
Incorrect choices:
A: Increasing protein intake can put additional strain on the kidneys and may lead to further deterioration of kidney function.
B: Increasing potassium intake can be dangerous for patients with chronic kidney disease as they may have difficulty regulating potassium levels.
D: Decreasing fluid intake may be necessary in some cases, but it is not the priority in terms of managing chronic kidney disease.
What is the most important intervention for a client experiencing an allergic reaction?
- A. Administer epinephrine
- B. Administer antihistamines
- C. Administer corticosteroids
- D. Administer beta-blockers
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis, a severe allergic reaction. It works by constricting blood vessels, increasing heart rate, and opening airways, which can reverse the life-threatening effects of an allergic reaction. Antihistamines (B) may help with mild symptoms but are not sufficient for severe reactions. Corticosteroids (C) are used to reduce inflammation but work too slowly for immediate relief. Beta-blockers (D) can worsen allergic reactions by blocking the effects of epinephrine.
What is the nurse's most appropriate response when a patient with hearing impairment is encountered?
- A. Assess the communication method preferred by the patient.
- B. Request the help of a sign language interpreter before meeting with the patient.
- C. Use loud and exaggerated facial movements when talking with the patient.
- D. Speak loudly and slowly because most older adults have hearing deficits.
Correct Answer: A
Rationale: The correct answer is A: Assess the communication method preferred by the patient. This response is appropriate because it demonstrates person-centered care by respecting the patient's communication preferences. By assessing the patient's preferred communication method, the nurse can effectively communicate with the patient and provide the best care.
Summary of other choices:
B: Requesting a sign language interpreter may not be necessary if the patient does not use sign language.
C: Using loud and exaggerated facial movements can be demeaning and ineffective in communication.
D: Assuming all older adults have hearing deficits is a stereotype and may not be accurate for every individual.