A nurse is caring for a patient with chronic liver disease. The nurse should monitor for which of the following complications?

Correct Answer: A

Rationale: The correct answer is A: Jaundice. In chronic liver disease, the liver is unable to properly process bilirubin, leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. It is a common complication of liver disease and indicates impaired liver function. Anemia (choice B) may occur in liver disease, but it is not the primary complication. Hyperglycemia (choice C) and hypoglycemia (choice D) are more commonly associated with diabetes or pancreatic disorders, rather than chronic liver disease. Therefore, monitoring for jaundice is crucial in the care of a patient with chronic liver disease.

Correct Answer: C

Rationale: The correct answer is C: Tremors and dizziness. Hypoglycemia is characterized by low blood sugar levels. Tremors and dizziness are common symptoms due to the brain not receiving enough glucose for energy. Tachycardia and nausea (choice A) are more indicative of hyperglycemia. Polyuria and polydipsia (choice B) are classic symptoms of hyperglycemia in diabetes. Weight loss and fatigue (choice D) are not specific symptoms of hypoglycemia.

Correct Answer: B

Rationale: Step 1: The review of systems is a systematic approach to assessing the patient's overall health. Step 2: It gathers information about symptoms across different body systems. Step 3: This information helps identify potential health risks and guide health promotion practices. Step 4: Choice B is correct as it aligns with the purpose of the review of systems. Summary: - Choice A is incorrect because it focuses on physical findings only, not the comprehensive assessment. - Choice C is incorrect as the review of systems is not primarily for teaching medical terms. - Choice D is incorrect as it does not provide enough information for diagnosing specific medical problems.

Correct Answer: D

Rationale: The correct answer is D because shortness of breath and respiratory distress indicate a potentially life-threatening emergency requiring immediate intervention. This problem falls under the first-level priority as it addresses airway, breathing, and circulation, which are essential for survival. Choices A, B, and C are not first-level priorities as they do not pose an immediate threat to the patient's life or require urgent intervention. Postoperative pain, diabetes teaching, and a small foot laceration are important but can be addressed at a later time without immediate harm to the patient.

Correct Answer: C

Rationale: The correct answer is C because a risk diagnosis involves identifying potential problems that an individual may develop in the future. This type of diagnosis focuses on preemptive measures to prevent or minimize the risk of these potential issues occurring. This is different from options A, B, and D, which do not pertain to future potential problems but rather current levels of wellness, past problems and goals, and strengths respectively. Therefore, option C best aligns with the concept of risk diagnosis in nursing classification.

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: 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: D

Rationale: The correct answer is D because it shows respect for the patient's belief and promotes open communication. By asking the patient to explain more about the hot-cold theory, the nurse acknowledges the patient's perspective and builds a trusting relationship. Option A dismisses the patient's belief, risking alienation. Option B is informative but misses the opportunity to understand the patient's cultural beliefs. Option C is unprofessional and does not address the patient's concerns.

Correct Answer: C

Rationale: The correct answer is C because prevention emphasizes the importance of personal behavior in maintaining health. It highlights the role of individual choices in preventing diseases and promoting well-being. A is incorrect because prevention focuses on proactive measures rather than treating external factors. B is incorrect as it contradicts the importance of prevention in reducing preventable deaths. D is incorrect because prevention is about avoiding health issues before they occur, not treating them after they have developed.