A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following assessments?

Correct Answer: A

Rationale: The correct answer is A: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.

Correct Answer: B

Rationale: The correct answer is B: Orientation, as it assesses a person's awareness of time, place, and person. This is crucial for evaluating cognitive functioning in mental health exams. Speech (A) is related to communication, Perception (C) involves interpreting sensory information, and Judgement (D) pertains to decision-making skills. However, in the context of a mental health examination, assessing orientation is essential for understanding a person's cognitive status and ability to interact with their environment effectively.

Correct Answer: C

Rationale: The most important goal for a nurse when implementing care for a patient with a chronic illness is to prevent future complications (Choice C). This is because chronic illnesses are long-term conditions that require ongoing management to minimize the risk of complications and improve the patient's quality of life. By preventing future complications, the nurse helps maintain the patient's health and prevents the progression of the disease. Providing emotional support (Choice D) is important but not the most crucial goal in this context. While reducing symptoms (Choice B) is important, preventing future complications takes precedence as it addresses the underlying cause of the illness. Curing the disease (Choice A) may not always be feasible for chronic illnesses, making prevention of complications a more realistic and essential goal.

Correct Answer: D

Rationale: I must correct you on this question. The correct answer for the most appropriate action for a nurse to take when a client develops a deep vein thrombosis (DVT) is not D. The correct answer should be C: Provide anticoagulant therapy. Anticoagulant therapy is the standard treatment for DVT to prevent the blood clot from getting larger and to reduce the risk of it breaking loose and causing a pulmonary embolism. Elevating the leg and applying compression can help with symptoms but are not the primary treatment for DVT. Massage is contraindicated as it can dislodge the blood clot.

Correct Answer: C

Rationale: The correct answer is C: Critical thinking. Critical thinking involves analyzing information, evaluating options, and making sound decisions. When caring for multiple clients with complex care, critical thinking enables nurses to prioritize tasks, anticipate complications, and adapt care plans accordingly. Diagnostic reasoning (A) is important but focuses on identifying specific health issues. Physical assessment (B) is crucial but only addresses one aspect of care. Nursing care plans (D) are essential tools but rely on critical thinking for effective implementation. In conclusion, critical thinking is the key as it encompasses all aspects of problem-solving in complex care situations.