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Which of the following are considered second-level priority problems?
- A. Low self-esteem.
- B. Lack of knowledge.
- C. Abnormal laboratory values.
- D. Severely abnormal vital signs.
Correct Answer: C
Rationale: The correct answer is C: Abnormal laboratory values. Second-level priority problems are those that are important to the patient's health but may not be life-threatening. Abnormal laboratory values fall into this category as they indicate an underlying health issue that needs attention. Low self-esteem (A) and lack of knowledge (B) are typically considered third-level priority problems, as they do not pose an immediate threat to the patient's health. Severely abnormal vital signs (D) are first-level priority problems, as they indicate an acute and potentially life-threatening situation that requires immediate intervention. Therefore, the correct answer is C as it aligns with the definition of second-level priority problems.
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Which of the following is the best indicator of a patient's nutritional status?
- A. Patient's weight
- B. Serum albumin levels
- C. Patient's food preferences
- D. Number of meals consumed per day
Correct Answer: B
Rationale: The correct answer is B: Serum albumin levels. Serum albumin is a protein produced by the liver and is a key indicator of a patient's nutritional status. Low levels of serum albumin indicate malnutrition or protein deficiency. Monitoring serum albumin levels provides an objective measure of the patient's overall nutritional status.
Choice A (Patient's weight) can be influenced by factors other than nutrition, such as fluid retention or muscle mass. Choice C (Patient's food preferences) does not provide direct information on the patient's actual nutritional intake. Choice D (Number of meals consumed per day) does not account for the quality or quantity of nutrients consumed in those meals.
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.
The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs audibly. Which of the following statements does the nurse know is most accurate, considering the concept of communication?
Correct Answer: B
Rationale: The correct answer is B because the woman's nonverbal cues (looking nervously at her hands, sighing audibly) indicate potential anxiety or stress. The nurse should acknowledge these cues and explore her feelings further to provide appropriate support. Option A is incorrect as it does not address the woman's nonverbal cues. Option C is incorrect as it assumes the woman is not genuinely excited about the pregnancy. Option D is incorrect as it overlooks the woman's nonverbal cues and does not address her potential emotional needs.
A nurse is teaching a patient about managing chronic pain. Which of the following strategies should the nurse emphasize?
- A. Increasing activity to improve function.
- B. Using medications only when absolutely necessary.
- C. Implementing physical therapy and exercises.
- D. Using complementary therapies such as meditation and relaxation.
Correct Answer: C
Rationale: The correct answer is C: Implementing physical therapy and exercises. This is crucial for managing chronic pain as it helps improve strength, flexibility, and overall function. Physical therapy can also address underlying issues contributing to pain. Choice A could worsen pain if not done appropriately. Choice B may be necessary but should not be the sole approach. Choice D can be beneficial but may not address the root cause of pain like physical therapy does.
When examining a patient, the nurse can assess mental health by:
- A. Examining the patient's electroencephalogram.
- B. Observing the patient as he or she performs an IQ test.
- C. Observing the patient and inferring health or dysfunction.
- D. Examining the patient's response to a specific set of questions.
Correct Answer: C
Rationale: The correct answer is C because observing the patient and inferring health or dysfunction allows the nurse to assess mental health holistically. This method considers various factors such as behavior, emotions, communication, and overall functioning. It provides a comprehensive view of the patient's mental well-being.
A: Examining the patient's electroencephalogram is more related to brain activity rather than mental health assessment.
B: Observing the patient as he or she performs an IQ test is limited to cognitive abilities and does not capture the full spectrum of mental health.
D: Examining the patient's response to a specific set of questions may not provide a complete picture of mental health as it focuses on specific aspects rather than overall assessment.