A nurse is assessing a patient with a history of diabetes and hypertension. The nurse should monitor for which of the following complications?

Correct Answer: A

Rationale: The correct answer is A: Chronic kidney disease (CKD). Patients with diabetes and hypertension are at increased risk for developing CKD due to the damaging effects of high blood sugar and elevated blood pressure on the kidneys. The nurse should monitor for signs and symptoms of kidney dysfunction such as proteinuria, elevated creatinine levels, and decreased glomerular filtration rate. B: Chronic pain is not directly related to the patient's history of diabetes and hypertension. While the patient may experience pain as a result of complications from these conditions, it is not the primary complication to monitor for in this case. C: Hypotension, or low blood pressure, is not a common complication associated with diabetes and hypertension. These conditions typically lead to high blood pressure rather than low blood pressure. D: Sepsis is a serious infection that can occur in any patient, but it is not a direct complication specifically related to diabetes and hypertension. Monitoring for sepsis would be important in a broader context but is not

Correct Answer: C

Rationale: Step 1: Nutrition is important for healing and energy. Step 2: Elimination is crucial for bowel and bladder function. Step 3: Comfort ensures the client's well-being. Step 4: Safety prevents complications. Step 5: ROM exercises can prevent muscle atrophy. Step 6: Transportation and isotonic exercises are not immediate priorities.

Correct Answer: B

Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. In hypoglycemia, the priority is to raise blood glucose levels quickly to prevent complications like seizures or loss of consciousness. Fast-acting carbs like juice or glucose tablets are the first-line treatment. Administering insulin (choice A) would lower blood sugar further. Administering an oral hypoglycemic agent (choice C) takes time to work and is not suitable for emergencies. Monitoring blood pressure (choice D) is important but not the priority in this situation.

Correct Answer: A

Rationale: The correct first step in managing a client with acute renal failure is to administer IV fluids (Choice A). This is crucial to ensure adequate hydration and maintain renal perfusion. By administering IV fluids, you can help improve kidney function and prevent further damage. Monitoring urine output (Choice B) is important but comes after addressing the fluid balance with IV fluids. Performing a CT scan (Choice C) is not typically the initial step in managing acute renal failure as it does not directly impact the patient's immediate condition. Administering diuretics (Choice D) can worsen the condition by further reducing kidney function, so it is not the recommended first step.

Correct Answer: B

Rationale: Correct Answer: B Rationale: Limiting alcohol intake reduces blood pressure. Reducing sodium intake also helps manage hypertension. Alcohol can increase blood pressure, while sodium can lead to fluid retention. The patient's statement shows understanding of the importance of both factors in managing hypertension. Other Choices: A: Increasing sodium intake worsens fluid retention and hypertension. C: Processed foods are often high in sodium and unhealthy fats, worsening hypertension. D: Reducing exercise can lead to weight gain and increased blood pressure, contrary to managing hypertension.

Correct Answer: D

Rationale: The correct response is D because it encourages the mother to provide specific information about the toddler's behavior indicating pain. This helps the nurse assess the severity and nature of the earache accurately. Options A and C are dismissive and may overlook a potential health issue. Option B suggests immediate action without gathering information first, which may not be necessary.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. This is the first action because epinephrine is the primary treatment for anaphylaxis, a severe allergic reaction that can be life-threatening. It works quickly to reverse the symptoms by constricting blood vessels and opening airways. Administering epinephrine promptly can prevent progression to severe complications such as respiratory distress or cardiovascular collapse. Placing the client in a supine position and administering oxygen (B) may be necessary but should not delay the administration of epinephrine. Administering fluids (C) may help maintain blood pressure but is not the priority in the acute phase of anaphylaxis. Antihistamines (D) are not effective for treating the severe symptoms of anaphylaxis and should not be the first-line treatment.

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for a client with advanced Parkinson's disease and gait issues is "A: Impaired Physical Mobility." This diagnosis accurately reflects the client's limited ability to move due to the disease's impact on coordination and muscle control. Impaired Physical Mobility addresses the specific issue of gait problems commonly seen in Parkinson's patients. Choice B, "Impaired Role Performance," does not directly address the physical limitations caused by the disease. Choice C, "Ineffective Role Performance," focuses more on the client's inability to fulfill societal roles rather than the physical aspect of gait issues. Choice D, "Powerlessness," does not capture the primary concern of impaired movement and mobility in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. In hypoglycemia, the priority is to raise the low blood sugar levels quickly. Administering glucose is the most direct and effective way to do so. Glucose will rapidly increase the blood sugar levels and help the client recover from hypoglycemia. Administering insulin (B) would further lower blood sugar levels. Administering glucagon (C) is used for severe hypoglycemia when the client is unconscious. Encouraging deep breathing (D) is not effective in treating hypoglycemia and does not address the immediate need to raise blood sugar levels.