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:

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.

Correct Answer: B

Rationale: The correct answer is B: Respiratory failure. Patients with COPD have impaired lung function, making them at risk for respiratory failure due to inadequate oxygenation. This can occur due to exacerbation of COPD, infections, or other factors. Monitoring for signs of respiratory distress is crucial. A: Pneumonia - While patients with COPD are at higher risk for pneumonia due to impaired lung function, respiratory failure is a more immediate and critical complication to monitor for in this scenario. C: Hypoglycemia - COPD does not directly increase the risk of hypoglycemia, so monitoring for this complication is not a priority in this case. D: Hypertension - Although some patients with COPD may have hypertension, it is not a common complication directly related to COPD. Monitoring for respiratory failure is more essential in this situation.

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.

Correct Answer: B

Rationale: The correct answer is B because the nurse's response was therapeutic by sharing her own experience to empathize with the patient. This helps establish a connection and validate the patient's feelings. It shows understanding without dismissing the patient's concerns. A is incorrect because the nurse did not provide false reassurance but offered a comforting perspective. C is incorrect as the nurse did not imply that medication was necessary but rather highlighted its availability as an option. D is incorrect since the response did not provide false assurance but rather shared personal experience to offer support.

Correct Answer: B

Rationale: The correct answer is B because encouraging deep breathing and coughing exercises helps to improve lung function and prevent complications in pneumonia. This intervention can help clear secretions, improve oxygenation, and prevent respiratory distress. Administering antibiotics (choice A) is important but not the priority for immediate patient care. Providing pain relief (choice C) is essential but addressing respiratory function is more critical. Monitoring oxygen saturation levels (choice D) is necessary, but promoting lung function through exercises takes precedence.

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.

Correct Answer: B

Rationale: Step 1: The review of systems is a systematic approach to assessing the patient's overall health. Step 2: It gathers information about symptoms across different body systems. Step 3: This information helps identify potential health risks and guide health promotion practices. Step 4: Choice B is correct as it aligns with the purpose of the review of systems. Summary: - Choice A is incorrect because it focuses on physical findings only, not the comprehensive assessment. - Choice C is incorrect as the review of systems is not primarily for teaching medical terms. - Choice D is incorrect as it does not provide enough information for diagnosing specific medical problems.

Correct Answer: B

Rationale: The correct answer is B: Administer an antiemetic as prescribed. Administering an antiemetic helps alleviate nausea and vomiting, providing relief to the patient. This action is based on evidence-based practice and helps improve the patient's comfort and well-being. Offering clear fluids immediately (choice A) may exacerbate nausea. Waiting for the nausea to subside on its own (choice C) may prolong the patient's discomfort. Assessing vital signs (choice D) is important but may not directly address the immediate symptom of nausea.

Correct Answer: B

Rationale: The correct answer is B: Increased wheezing and shortness of breath. During an asthma exacerbation, bronchial airways become inflamed and narrowed, leading to increased wheezing and shortness of breath. This is a classic sign of worsening asthma. Other choices are incorrect because: A) Decreased work of breathing is not expected in an asthma exacerbation as the patient usually struggles to breathe. C) Improved oxygen saturation is unlikely as airway obstruction can lead to decreased oxygen levels. D) Decreased sputum production is not a typical sign of asthma exacerbation; in fact, increased sputum production may occur due to airway inflammation.