Nokea
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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Which statement is correct regarding the development of one's culture?
- A. Culture is genetically determined on the basis of racial background.
- B. Culture is rooted in several distinctive and specific social elements.
- C. Culture is a nonspecific phenomenon and is adaptive, but unnecessary.
- D. Culture is biologically determined on the basis of physical characteristics.
Correct Answer: B
Rationale: The correct answer is B because culture is indeed rooted in specific social elements such as language, customs, traditions, beliefs, and values. These elements are passed down through generations within a particular society or group. Choice A is incorrect because culture is not genetically determined, but rather learned and acquired through socialization. Choice C is incorrect as culture plays a crucial role in shaping identities, behaviors, and interactions within a society. Choice D is incorrect as culture is not biologically determined, but rather socially constructed.
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.
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
- A. Examine only the body areas related to the problem for which the patient is hospitalized, and then do a complete assessment after the problem has been resolved.
- B. Perform a mini-database by examining the body areas directly related to the problem for which the patient is hospitalized.
- C. Consider this a normal finding, and proceed with the abdominal assessment.
- D. Examine the entire body to determine if the problem is linked to something else.
Correct Answer: A
Rationale: The correct answer is A because when a patient is experiencing significant shortness of breath, the nurse should initially focus on assessing the areas directly related to the presenting problem to address the immediate issue. This approach allows for prompt intervention and treatment of the patient's acute condition. Once the patient's respiratory distress is managed, the nurse can then proceed with a complete assessment to identify any underlying or additional health issues. This stepwise approach ensures that the patient's urgent needs are met first before conducting a comprehensive assessment.
Choices B, C, and D are incorrect because:
B: Performing a mini-database by only examining body areas directly related to the problem may not provide a comprehensive understanding of the patient's condition and could overlook other potential health issues.
C: Dismissing significant shortness of breath as a normal finding and proceeding with an abdominal assessment is inappropriate and could delay necessary interventions for the respiratory distress.
D: Examining the entire body to determine if the problem is linked to something else is inefficient and
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.
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.