A nurse is caring for a patient with chronic heart failure. The nurse should monitor for which of the following signs of fluid overload?

Correct Answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. In chronic heart failure, fluid overload can lead to pulmonary congestion, causing shortness of breath. Weight gain is also a key sign of fluid retention. Increased urine output and hypotension (choice B) are more indicative of dehydration. Fatigue and dizziness (choice C) can be nonspecific symptoms and not directly related to fluid overload. Dry mouth and thirst (choice D) are symptoms of dehydration rather than fluid overload in chronic heart failure. Monitoring for shortness of breath and weight gain allows for early detection and intervention in managing fluid overload in patients with chronic heart failure.

Correct Answer: B

Rationale: The correct answer is B: Pernicious anemia. This condition is characterized by a deficiency in vitamin B12, leading to neurological symptoms like tingling sensations in the feet (peripheral neuropathy) and glossitis, causing the tongue to become red and painful. Polycythemia (A) is an increase in red blood cell mass, not related to the symptoms described. Micronucleus anemia (C) is not a recognized medical condition. Iron-deficiency anemia (D) can lead to symptoms like fatigue and pallor, but not typically tingling sensations in the feet or glossitis.

Correct Answer: A

Rationale: The correct approach is to defer the rest of the mental health examination. This is because the patient's symptoms of dysarthria and lethargy indicate a potential medical emergency or brain injury, which should take precedence over the mental health assessment. It is important to first ensure the patient's physical well-being before proceeding with the mental health evaluation. Choice B is incorrect as skipping the language portion of the examination may overlook crucial information related to the patient's condition. Choice C is also incorrect as an in-depth speech evaluation may delay necessary medical interventions. Choice D is incorrect as assuming dysarthria is always linked to severe depression can lead to overlooking urgent medical needs.

Correct Answer: B

Rationale: The correct answer is B: Increased shortness of breath. During a COPD exacerbation, airflow limitation worsens, leading to increased difficulty in breathing. This is a common sign due to air trapping and inflammation in the airways. Sudden weight gain (A) is not typically associated with COPD exacerbation. Decreased heart rate (C) is not a common sign and is more likely to occur in other conditions. Increased energy levels (D) are unlikely during a COPD exacerbation as the body is under stress from impaired lung function.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis. Patients with a history of stroke are at an increased risk of developing deep vein thrombosis due to immobility and vascular damage. This complication can lead to serious consequences, such as pulmonary embolism. Monitoring for signs of deep vein thrombosis, such as leg swelling and pain, is crucial for early detection and intervention. Severe dehydration (A), liver failure (C), and pulmonary embolism (D) are less likely complications in a patient with a history of stroke compared to deep vein thrombosis.

Correct Answer: A

Rationale: The correct answer is A because using the defrost setting on microwave ovens can help safely heat breast milk or formula for the infant without compromising its quality. This method ensures that the milk is heated evenly and prevents hot spots that could burn the baby's mouth. Choice B is incorrect because refrigerating partially used bottles can lead to bacterial growth and contamination. Choice C is incorrect as mixing water and concentrate in different ratios can result in either too diluted or too concentrated formula, which can be harmful to the infant. Choice D is incorrect as adding new formula to partially used bottles can also lead to bacterial growth and spoilage.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin helps prevent further clot formation by inhibiting platelet aggregation, reducing the risk of additional heart damage. It is a standard treatment in acute myocardial infarction. Administering morphine (B) may be considered for pain relief but is not the primary intervention. Monitoring vital signs (C) is important, but not the primary intervention. Administering fibrinolytics (D) is indicated in certain cases but is not the primary intervention and requires specific criteria and caution.

Correct Answer: B

Rationale: Step 1: Patient stating they can stop taking medication once BP is normal shows misunderstanding of hypertension as a chronic condition. Step 2: Hypertension requires long-term management even if BP is controlled temporarily. Step 3: Stopping medication abruptly can lead to BP spikes and complications. Step 4: Other choices (A, C, D) demonstrate good understanding and proactive approach to managing hypertension. Summary: Choice B is incorrect as it suggests discontinuation of medication, posing a risk to the patient's health. Choices A, C, and D show positive behaviors towards hypertension management.

Correct Answer: C

Rationale: The correct answer is C: Severity. In the PQRSTU mnemonic, "S" stands for Severity, which refers to the intensity or seriousness of the symptoms experienced by the patient. This is crucial in assessing the impact of the problem on the patient's health and well-being. Incorrect choices: A: Swelling - Swelling is a physical symptom and does not encompass all aspects of the patient's perception. B: Subjectivity - While the patient's subjective experience is important, it does not specifically refer to severity. D: Symptoms - While symptoms are part of the patient's perception, the "S" in PQRSTU specifically focuses on the severity of those symptoms.