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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.
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A patient tells the nurse that she believes in "the hot"“cold theory, where illness is caused by hot or cold entering the body." Which of the following responses from the nurse would be most appropriate?
- A. I do not believe in this theory, but tell me about it.
- B. I know that this is your belief, but the cause is actually a virus.
- C. I did not take this in school, so it's unfamiliar to me.
- D. I have not heard of this theory. Tell me more.
Correct Answer: D
Rationale: The correct answer is D because it shows respect for the patient's belief and promotes open communication. By asking the patient to explain more about the hot-cold theory, the nurse acknowledges the patient's perspective and builds a trusting relationship. Option A dismisses the patient's belief, risking alienation. Option B is informative but misses the opportunity to understand the patient's cultural beliefs. Option C is unprofessional and does not address the patient's concerns.
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.
A family who immigrated to Canada 3 months ago has come to the clinic to see the nurse practitioner. One of the parents has found work, but not in his fielThe other parent has not been able to find a joThis family of five is living in a one-bedroom apartment. The nurse practitioner is aware that the health of new immigrants is:
- A. negatively affected, as a result of many contributing factors.
- B. positively affected by having access to modern urban hospitals.
- C. unlikely to change without help from government programs.
- D. improved by employment and stable housing.
Correct Answer: A
Rationale: Step 1: New immigrants face many challenges such as language barriers, cultural differences, lack of social support, and limited access to healthcare.
Step 2: These factors can negatively impact their health by causing stress, mental health issues, and difficulties in accessing healthcare services.
Step 3: Employment and stable housing are important factors for immigrants' health, but they alone may not address the broader issues affecting their well-being.
Step 4: Therefore, the correct answer is A, as the health of new immigrants is indeed negatively affected by a combination of contributing factors beyond just employment and housing.
A nurse is caring for a patient with a history of hypertension. The nurse should educate the patient to prioritize which of the following?
- A. Limiting sodium intake.
- B. Increasing potassium intake.
- C. Increasing fluid intake.
- D. Consuming more caffeine.
Correct Answer: A
Rationale: The correct answer is A: Limiting sodium intake. This is crucial for a patient with hypertension as excess sodium can lead to increased blood pressure. Sodium intake should be limited to lower the risk of cardiovascular complications.
B: Increasing potassium intake is beneficial, but not as critical as limiting sodium for hypertension management.
C: Increasing fluid intake may or may not be necessary depending on the patient's condition, but it is not as crucial as limiting sodium for hypertension management.
D: Consuming more caffeine can actually elevate blood pressure, so it is not recommended for patients with hypertension.
A nurse is caring for a patient with a history of hypertension and diabetes. The nurse should monitor for which of the following complications?
- A. Hyperglycemia.
- B. Stroke.
- C. Hypokalemia.
- D. Hypoglycemia.
Correct Answer: B
Rationale: Step 1: The patient has a history of hypertension and diabetes, putting them at risk for cardiovascular complications.
Step 2: Among the choices, stroke is a common complication associated with uncontrolled hypertension and diabetes.
Step 3: Monitoring for signs of stroke is crucial to prevent serious consequences in this patient population.
Step 4: Hyperglycemia (A) is a common complication of diabetes, but it is not directly related to the patient's hypertension.
Step 5: Hypokalemia (C) is an electrolyte imbalance that can occur in some conditions but is not as directly linked to the patient's history.
Step 6: Hypoglycemia (D) is a potential complication in diabetic patients but is not as common as hyperglycemia and is not directly related to hypertension.