A nurse is caring for a 75-year-old patient with diabetes. What is the most important nursing action when assessing this patient?

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's level of understanding about diabetes management. This is the most important nursing action because it enables the nurse to tailor education and interventions to the patient's specific needs. By assessing the patient's understanding, the nurse can address any misconceptions, provide appropriate education, and promote self-management. Checking blood sugar levels every hour (B) is excessive and not necessary unless indicated. Instructing the patient to avoid all sugar-containing foods (C) is overly restrictive and not evidence-based. Ensuring the patient is compliant with their insulin regimen (D) is important but assessing understanding is crucial for effective diabetes management.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Assessing the communication method preferred by the patient is crucial as it allows the nurse to tailor the communication approach to the patient's needs. 2. By understanding the patient's preferred communication method, the nurse can ensure effective and respectful communication. 3. This approach promotes patient-centered care and fosters a positive therapeutic relationship. 4. Avoiding facial expressions and hand gestures (B) can hinder communication and may not align with the patient's preferences. 5. Requesting a sign language interpreter (C) may be necessary for some patients, but assessing the patient's preferred method should be the initial step. 6. Speaking loudly and with exaggerated facial movement (D) can be ineffective and may not be the patient's preferred method of communication.

Correct Answer: C

Rationale: The correct answer is C: Using biased or leading questions. This question is biased and leading because it assumes that the patients attending the workshop do not engage in smoking, drinking, or drug use. It may influence the patients to provide inaccurate information if they feel pressured to conform to societal expectations. In health assessments, it is important to ask open-ended, non-judgmental questions to gather accurate and comprehensive information. Incorrect choices: A: Talking too much - This choice is not relevant to the question as it does not address the issue of biased or leading questions. B: Using confrontation - This choice does not apply as the question does not involve confronting the patients. D: Using blunt language to deal with distasteful topics - While the question may be blunt, the main issue is the bias and leading nature of the question, not its bluntness.

Correct Answer: D

Rationale: The correct answer is D because it directly asks for specific information about past hospitalizations, prompting Mr. Y to recall the last time he was admitted for chest pain. This question is open-ended, allowing Mr. Y to provide detailed information voluntarily. A is incorrect as it assumes Mr. Y has been hospitalized without directly asking for that information. B is a better choice but lacks specificity in requesting details about past hospitalizations. C is inappropriate as it assumes permission to access medical records without Mr. Y's consent.

Correct Answer: C

Rationale: The correct answer is C: Begin with the head. This is the most appropriate action as starting with the head allows the nurse to establish rapport with the infant and assess their level of alertness before progressing further. By starting at the head, the nurse can also observe the infant's facial expressions and interactions with the caregiver, providing valuable information about the infant's overall well-being. Assessing reflexes first (Choice A) may startle the infant, asking the parent to undress the child (Choice B) can be done after the initial assessment, and beginning with the legs (Choice D) does not prioritize the critical areas of observation such as the head and face.