A nurse is assessing a patient with a history of stroke. The nurse should monitor for signs of which of the following complications?

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.

Correct Answer: A

Rationale: The correct answer is A: Administer pain medication. This is the most appropriate nursing intervention because severe pain post-surgery requires immediate relief to ensure the client's comfort and aid in recovery. Pain medication helps manage pain effectively, improving the client's overall well-being and promoting healing. Monitoring vital signs (choice B) is important but secondary to pain relief in this scenario. Administering IV fluids (choice C) may be necessary for hydration but does not directly address the pain. Administering corticosteroids (choice D) is not typically indicated for severe pain post-surgery.

Correct Answer: B

Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). The patient's history of smoking, persistent cough, and worsening symptoms over months are indicative of COPD, a progressive lung disease commonly caused by smoking. Asthma (A) typically presents with intermittent symptoms, bronchitis (C) may cause cough but not necessarily worsening over time, and pulmonary embolism (D) is characterized by sudden onset symptoms and is less likely in this case. COPD is the most concerning due to the patient's smoking history and progressive symptoms.

Correct Answer: B

Rationale: The correct answer is B: gout. Uric acid levels are typically checked for gout, a type of arthritis caused by the buildup of uric acid crystals in the joints. This condition directly relates to uric acid levels in the blood. Asthma (choice A), diverticulitis (choice C), and meningitis (choice D) do not typically require checking uric acid levels. Asthma is a respiratory condition, diverticulitis is a gastrointestinal condition, and meningitis is an inflammation of the protective membranes covering the brain and spinal cord.

Correct Answer: A

Rationale: The correct answer is A because memory loss after a fall can be indicative of a more serious issue like a head injury or neurological problem. A complete mental health examination by the nurse can help assess the extent of memory loss, identify potential causes, and determine appropriate interventions. Referring to a psychometrician (choice B) may not address the immediate health concern. Integrating the mental health examination into history taking and physical examination (choice C) is important but may not be as thorough as a complete mental health examination by a professional. Reassuring the wife that memory loss is normal (choice D) may lead to overlooking a potentially serious health issue.

Correct Answer: A

Rationale: The correct answer is A: database. The patient's record, laboratory studies, objective data, and subjective data collectively form the database in healthcare. This term refers to a comprehensive collection of all pertinent information about a patient that is used for analysis, diagnosis, and treatment planning. The other choices are incorrect because B: admitting data specifically refers to information gathered at the time of admission, C: financial statement pertains to financial information, and D: discharge summary summarizes the patient's care and treatment at the time of discharge, not the entire patient record.

Correct Answer: A

Rationale: Correct Answer: A (Iron, folic acid, and B12) Rationale: 1. Iron: Renal failure patients often have anemia due to decreased erythropoietin production. 2. Folic acid and B12: Important for red blood cell production and maturation. 3. Corrects underlying causes of anemia in renal failure patients. Summary: B: Increasing protein doesn't directly address anemia in renal failure. C: Vitamin D and calcium are not primary treatments for anemia in renal failure. D: Calcium and folic acid alone do not address the specific deficiencies seen in renal failure anemia.

Correct Answer: B

Rationale: The correct answer is B: Administer antibiotics. When caring for a client with severe burns, the first priority is to prevent infection, which can be life-threatening. Administering antibiotics helps reduce the risk of infection. Cleansing and dressing the wounds can come after ensuring infection control. Performing a tracheostomy is not typically the first priority unless there are airway concerns. Administering analgesics is important, but it is not the first priority in this case.

Correct Answer: C

Rationale: The correct answer is C: Mental. Nursing assessments typically include physical, focused, and emergency assessments. Mental assessments are more commonly associated with psychiatric nursing rather than general nursing assessments. Mental assessments focus on assessing a patient's mental status, emotions, and cognitive functions, which are not typically part of routine nursing assessments. Therefore, mental assessments do not fall under the types of assessments typically performed by general nurses.