A nurse is caring for a patient with a history of alcohol abuse. The nurse should be aware that this patient is at increased risk for which of the following complications?

Correct Answer: A

Rationale: The correct answer is A: Chronic liver disease. Patients with a history of alcohol abuse are at increased risk for chronic liver disease due to the toxic effects of alcohol on the liver. Alcohol can lead to fatty liver, alcoholic hepatitis, cirrhosis, and liver cancer. The liver plays a crucial role in metabolizing alcohol, and excessive alcohol consumption can overwhelm the liver's ability to detoxify the body. Chronic kidney disease (B), pulmonary embolism (C), and stroke (D) are not directly associated with alcohol abuse. Kidney disease is more commonly linked to conditions like diabetes and hypertension, pulmonary embolism is often related to blood clotting disorders, and stroke can be caused by factors such as hypertension and atherosclerosis.

Correct Answer: D

Rationale: The correct answer is D: Rotate injection sites to prevent lipodystrophy. Rotating injection sites helps prevent the development of lipodystrophy, a condition characterized by the loss of fat tissue at the injection site. This is important for maintaining consistent insulin absorption and reducing the risk of injection site complications. A: Storing insulin at room temperature is generally recommended, but it is not the most critical action for insulin administration. B: Using insulin immediately after drawing it up is not necessary for all types of insulin and may not be feasible in all situations. C: Injecting insulin into the same spot can lead to tissue damage and inconsistent insulin absorption, so it should be avoided.

Correct Answer: D

Rationale: The correct answer is D: Hyperglycemia. In diabetes, hyperglycemia occurs when blood sugar levels are too high. This can lead to various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. Monitoring for hyperglycemia is crucial to prevent these serious complications. A: Hypoglycemia is low blood sugar and can also occur in diabetes, but it is not the primary complication to monitor for in this case. B: Hyperkalemia is high potassium levels and is not a common complication of diabetes unless there are other underlying issues. C: Hypotension is low blood pressure, which can be a complication of diabetes but is not as directly related to glucose management as hyperglycemia. In summary, monitoring for hyperglycemia is essential in diabetes care to prevent serious complications associated with high blood sugar levels.

Correct Answer: C

Rationale: Rationale: 1. Nursing diagnoses evaluate the response of the whole person to health problems, not just specific organ systems. 2. They focus on the individual's physical, emotional, social, and spiritual well-being. 3. Nursing diagnoses are independent of medical diagnoses and consider the person holistically. 4. Option C aligns with the nursing process and the holistic approach of nursing care. Summary: Option A is incorrect as nursing diagnoses do not solely evaluate the etiology of disease. Option B is incorrect as nursing diagnoses are independent of medical diagnoses. Option D is incorrect as nursing diagnoses focus on the whole person, not just specific organ systems.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates a rapid succession of loosely associated thoughts, typical of flight of ideas. The statement transitions from discussing a pill to the color red, then red velvet, and finally to a baby's bottom. This rapid and disjointed flow of thoughts is characteristic of flight of ideas, a symptom commonly seen in manic episodes of bipolar disorder. Choices A, B, and D do not exhibit the same level of rapid and tangential thoughts as choice C, making them incorrect.

Correct Answer: C

Rationale: Step 1: Post-operative patients are at risk for developing pneumonia due to decreased lung expansion and secretion retention. Step 2: Deep breathing exercises help improve lung expansion and prevent pneumonia. Step 3: Therefore, encouraging the patient to perform deep breathing exercises is essential. Summary: - A: Avoiding deep breathing exercises is incorrect as it can lead to respiratory complications. - B: Taking shallow breaths can worsen lung function and increase the risk of pneumonia. - D: Limiting mobility can lead to complications like blood clots and pneumonia.

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

Correct Answer: A

Rationale: The correct answer is A: Oxygen saturation levels. This assessment is crucial in pneumonia to ensure adequate oxygenation. Low oxygen levels can lead to respiratory distress. Pain levels (B) are important but not a priority over oxygenation. Bowel sounds (C) are not directly related to pneumonia. Level of consciousness (D) is also important but not as critical as ensuring proper oxygen levels for a patient with pneumonia. Oxygen saturation levels should be prioritized to prevent complications and ensure the patient's respiratory status is stable.

Correct Answer: C

Rationale: The correct answer is C, hypercapnia. In COPD, impaired lung function leads to inadequate oxygen exchange, causing increased carbon dioxide levels in the blood (hypercapnia). This can result in respiratory acidosis and further exacerbate respiratory distress. Monitoring for hypercapnia is crucial in COPD management to prevent respiratory failure. Incorrect choices: A: Pulmonary embolism - While patients with COPD are at increased risk for blood clots, pulmonary embolism is not a direct complication of COPD. B: Pneumothorax - Although individuals with COPD may develop pneumothorax due to weakened lung tissue, it is not a common complication. D: Asthma attack - Asthma and COPD are distinct conditions with different pathophysiology. Asthma attacks are not a typical complication of COPD.