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Which of the following is an example of a first-level priority problem?
- A. A patient with postoperative pain.
- B. A patient newly diagnosed with diabetes who needs teaching about diabetes.
- C. An individual with a small laceration on the sole of the foot.
- D. An individual with shortness of breath and respiratory distress.
Correct Answer: D
Rationale: The correct answer is D because shortness of breath and respiratory distress indicate a potentially life-threatening emergency requiring immediate intervention. This problem falls under the first-level priority as it addresses airway, breathing, and circulation, which are essential for survival. Choices A, B, and C are not first-level priorities as they do not pose an immediate threat to the patient's life or require urgent intervention. Postoperative pain, diabetes teaching, and a small foot laceration are important but can be addressed at a later time without immediate harm to the patient.
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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.
When nursing diagnoses are being classified, which of the following would be considered a risk diagnosis?
- A. Identifying existing levels of wellness
- B. Evaluating previous problems and goals
- C. Identifying potential problems the individual may develop
- D. Focusing on strengths and reflecting an individual's transition to higher levels of wellness
Correct Answer: C
Rationale: The correct answer is C because a risk diagnosis involves identifying potential problems that an individual may develop in the future. This type of diagnosis focuses on preemptive measures to prevent or minimize the risk of these potential issues occurring. This is different from options A, B, and D, which do not pertain to future potential problems but rather current levels of wellness, past problems and goals, and strengths respectively. Therefore, option C best aligns with the concept of risk diagnosis in nursing classification.
A 40-year-old woman presents to the clinic with complaints of fatigue and weight gain. On assessment, the nurse finds that the patient has cold intolerance, dry skin, and a slow heart rate. The nurse suspects:
- A. Hyperthyroidism.
- B. Hypothyroidism.
- C. Cushing's syndrome.
- D. Addison's disease.
Correct Answer: B
Rationale: The correct answer is B: Hypothyroidism. In this case, the patient's symptoms of fatigue, weight gain, cold intolerance, dry skin, and slow heart rate are indicative of hypothyroidism. The thyroid gland is underactive, leading to decreased production of thyroid hormones, which regulate metabolism. These symptoms align with the typical clinical presentation of hypothyroidism. Other choices are incorrect because hyperthyroidism (choice A) would present with symptoms like weight loss, heat intolerance, and a fast heart rate. Cushing's syndrome (choice C) and Addison's disease (choice D) are both conditions related to the adrenal glands and would have different symptom presentations compared to what is described in the case scenario.
A nurse is teaching a patient with asthma about managing an asthma attack. Which of the following statements by the patient indicates proper understanding?
- A. I will use my inhaler every time I feel an asthma attack coming on.
- B. I will wait for the symptoms to subside on their own before using my inhaler.
- C. I will use my inhaler even if I don't feel any symptoms.
- D. I will not use my inhaler if my symptoms are mild.
Correct Answer: A
Rationale: Rationale: Choice A is correct because using the inhaler at the onset of symptoms can help prevent the asthma attack from worsening. This early intervention can be crucial in managing asthma effectively. Waiting for symptoms to subside (Choice B) can be risky as it may delay necessary treatment. Using the inhaler preventively (Choice C) without symptoms is unnecessary and can lead to overuse. Not using the inhaler for mild symptoms (Choice D) can allow the condition to escalate. Thus, Choice A is the most appropriate response for managing an asthma attack effectively.
A female nurse is interviewing a male patient who is close in age to the nurse. During the interview, the patient makes an overtly sexual comment. The nurse's best response would be:
- A. Stop that immediately!
- B. Oh, you are too funny. Let's keep going with the interview.
- C. Do you really think I'd be interested?
- D. It makes me uncomfortable when you talk that way. Please don't.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the inappropriate behavior, sets a boundary, and communicates the nurse's discomfort in a professional manner. By stating that the comment makes them uncomfortable and asking the patient to refrain from such behavior, the nurse asserts their professionalism while maintaining respect for both parties. Choice A is too abrupt and may escalate the situation. Choice B dismisses the behavior, which is inappropriate. Choice C could be perceived as confrontational and potentially lead to a defensive response from the patient.