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

Correct Answer: B

Rationale: Step 1: The patient has a history of hypertension and diabetes, putting them at risk for cardiovascular complications. Step 2: Among the choices, stroke is a common complication associated with uncontrolled hypertension and diabetes. Step 3: Monitoring for signs of stroke is crucial to prevent serious consequences in this patient population. Step 4: Hyperglycemia (A) is a common complication of diabetes, but it is not directly related to the patient's hypertension. Step 5: Hypokalemia (C) is an electrolyte imbalance that can occur in some conditions but is not as directly linked to the patient's history. Step 6: Hypoglycemia (D) is a potential complication in diabetic patients but is not as common as hyperglycemia and is not directly related to hypertension.

Correct Answer: B

Rationale: The correct answer is B, Blood pressure. Dizziness, blurred vision, and nausea can be symptoms of hypotension or hypertension. Assessing the patient's blood pressure first is crucial to determine if the symptoms are related to blood pressure fluctuations. Electrolyte levels (A) and blood glucose levels (C) may be assessed later but do not address the immediate concern. Temperature and respiratory rate (D) are important assessments but are not the priority in this scenario where cardiovascular status needs to be evaluated first.

Correct Answer: A

Rationale: The correct answer is A: Hypertensive crisis. The nurse should be most concerned about this option because the patient has a history of hypertension and is experiencing new onset symptoms such as headaches, nausea, and dizziness, which could indicate a sudden and severe increase in blood pressure. This condition, if left untreated, can lead to serious complications such as stroke or heart attack. Summary: - B: Migraine headache is unlikely as the symptoms described are not typical of a migraine. - C: Benign positional vertigo is unlikely as it does not explain the presence of headaches and nausea. - D: Tension headache is less concerning compared to hypertensive crisis, given the patient's history of hypertension and the severity of symptoms.

Correct Answer: A

Rationale: The correct answer is A, shortness of breath and weight gain, because fluid overload in patients with chronic kidney disease can lead to pulmonary edema and weight gain due to retained fluid. Shortness of breath occurs as the excess fluid accumulates in the lungs. Increased urine output and fatigue (B) are more indicative of dehydration. Dizziness and hypotension (C) are symptoms of hypovolemia, not fluid overload. Nausea and vomiting (D) are nonspecific symptoms and not typically associated with fluid overload.

Correct Answer: D

Rationale: The correct answer is D: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels, leading to hyperglycemia. This can result in various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. The nurse should monitor the patient's blood glucose levels regularly to prevent these serious complications. Explanation for incorrect choices: A: Hypoglycemia - While hypoglycemia is a concern for diabetic patients, hyperglycemia is a more common and immediate risk. B: Hyperkalemia - While hyperkalemia can occur in some diabetic patients, hyperglycemia is a more common and primary concern. C: Hypotension - While diabetic patients can experience hypotension, hyperglycemia poses a more immediate threat to their health.

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: A

Rationale: Correct Answer: A Rationale: 1. Regular blood glucose monitoring helps in understanding patterns and making informed decisions. 2. Adjusting insulin based on blood glucose levels is crucial for effective diabetes management. 3. This statement shows the patient's understanding of the need for personalized insulin adjustments. 4. It promotes self-management and proactive approach to blood sugar control. Summary: B: Stopping insulin abruptly can lead to dangerous complications. C: Skipping meals can disrupt blood sugar levels and is not recommended. D: Waiting for high blood sugar to use insulin can result in uncontrolled levels and complications.

Correct Answer: C

Rationale: The correct answer is C: Please point to articles in the room and parts of the body as I name them. This is the most important assessment for mental health in an aphasic patient post-stroke because it evaluates their comprehension, communication abilities, and cognitive function. Pointing to articles and body parts demonstrates understanding and ability to follow instructions, which are crucial aspects of mental health assessment in this context. A: Please count back from 100 by sevens - This choice involves memory and mathematical abilities, which may not accurately assess mental health in an aphasic patient. B: I will name three items and ask you to repeat them in a few minutes - This choice tests memory recall, which is not as relevant for assessing mental health in an aphasic patient post-stroke. D: What would you do if you found a stamped, addressed envelope on the sidewalk? - This choice assesses problem-solving skills, which may not be the most appropriate indicator of mental health in an aphasic patient.

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.