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Which of the following statements represents subjective data about the patient's skin?
- A. Skin dry in appearance
- B. No obvious lesions
- C. Denies colour change
- D. Lesion noted lateral aspect right arm
Correct Answer: C
Rationale: The correct answer is C because it indicates that the information was provided directly by the patient and is based on their perception or feeling. Subjective data is based on the patient's experiences and cannot be observed or measured by others. Choices A, B, and D are all objective data as they can be observed or measured by healthcare providers. Choice A describes a visible characteristic of the skin, choice B indicates absence of observable lesions, and choice D reports an observed lesion on a specific location of the skin. Therefore, choice C is the only option that reflects subjective data about the patient's skin.
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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.
A nurse is teaching a patient with osteoarthritis about managing their condition. Which of the following statements by the patient indicates the need for further education?
- A. I will use heat or cold therapy to relieve joint pain.
- B. I will take my pain medication regularly.
- C. I will exercise regularly to strengthen my joints.
- D. I will avoid physical activity to prevent joint strain.
Correct Answer: D
Rationale: The correct answer is D because avoiding physical activity to prevent joint strain is not recommended for managing osteoarthritis. Exercise is crucial for strengthening joints and improving flexibility. Choice A is correct as heat or cold therapy can help relieve joint pain. Choice B is correct as taking pain medication regularly can help manage symptoms. Choice C is correct as regular exercise is important for maintaining joint health. In summary, avoiding physical activity is not a recommended approach for managing osteoarthritis, unlike the other choices which are beneficial for the condition.
A nurse is caring for a patient with a history of chronic asthma. The nurse should prioritize monitoring for which of the following complications?
- A. Pneumothorax.
- B. Hyperglycemia.
- C. Respiratory failure.
- D. Chronic renal failure.
Correct Answer: C
Rationale: The correct answer is C: Respiratory failure. For a patient with chronic asthma, the priority complication to monitor for is respiratory failure as it can be life-threatening. Asthma is a chronic respiratory condition that can lead to severe bronchoconstriction and impaired gas exchange, potentially resulting in respiratory failure. Monitoring for signs such as increased respiratory rate, use of accessory muscles, decreased oxygen saturation, and altered mental status is crucial. Pneumothorax (A) is a possible complication but less common in chronic asthma. Hyperglycemia (B) and chronic renal failure (D) are not directly related to asthma and are not the primary complications to monitor for in this case.
A nurse is caring for a patient with diabetes who is experiencing diabetic neuropathy. The nurse should prioritize which of the following interventions?
- A. Encouraging regular foot inspections.
- B. Providing additional protein to the diet.
- C. Encouraging weight loss to reduce joint stress.
- D. Administering pain medication for relief.
Correct Answer: A
Rationale: The correct answer is A: Encouraging regular foot inspections. This is the priority intervention because diabetic neuropathy can lead to decreased sensation in the feet, increasing the risk of injury or infection. Regular foot inspections can help detect any issues early and prevent complications.
Incorrect choices:
B: Providing additional protein to the diet - While nutrition is important for overall health, providing additional protein does not directly address the specific issue of diabetic neuropathy.
C: Encouraging weight loss to reduce joint stress - Weight loss may be beneficial for overall health, but it is not the priority intervention for diabetic neuropathy.
D: Administering pain medication for relief - Pain management is important, but addressing the root cause through regular foot inspections is more essential in preventing further complications.
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.