A nurse is caring for a patient with diabetes who is receiving insulin. The nurse should be most concerned if the patient experiences:

Correct Answer: C

Rationale: The correct answer is C: Dizziness and shakiness. This indicates hypoglycemia, a potential side effect of insulin therapy. Dizziness and shakiness are classic signs of low blood sugar levels, which can be dangerous if left untreated. Headache and blurred vision (Option A) can occur with high blood sugar. Increased thirst and urination (Option B) are symptoms of hyperglycemia. Dry mouth and skin (Option D) are not immediate concerns related to insulin therapy.

Correct Answer: B

Rationale: The correct assessment is B because providing consistent information indicates reliability. Drug abuse history (A) does not necessarily mean the patient is unreliable. Smiling (C) is not a reliable indicator. Refusal to answer specific questions (D) does not negate overall reliability.

Correct Answer: D

Rationale: The correct answer is D: Both B and C. After knee replacement surgery, patients are at risk for developing DVT and pulmonary embolism due to immobility and surgery-related factors. DVT occurs when a blood clot forms in a deep vein, usually in the legs, which can lead to a pulmonary embolism if the clot travels to the lungs. Monitoring for both complications is crucial to prevent serious consequences. Option A, hyperglycemia, is not a common complication following knee replacement surgery and is not directly related to immobility or surgery. Option B, DVT, is correct but does not encompass the risk of pulmonary embolism. Option C, pulmonary embolism, is correct but does not cover the initial risk of DVT formation. Therefore, monitoring for both DVT and pulmonary embolism is essential in post-operative knee replacement patients.

Correct Answer: A

Rationale: The correct answer is A: Monitoring blood glucose levels regularly. This is crucial in managing type 2 diabetes because it helps the patient understand how their body responds to food, medication, and activity. By tracking blood glucose levels, the patient can make informed decisions about their diet, medication, and lifestyle choices. This proactive approach enables early detection of fluctuations in blood sugar levels, allowing for prompt adjustments to prevent complications. Summary: - Choice A is correct as monitoring blood glucose levels is essential for managing type 2 diabetes. - Choice B is important but secondary to monitoring blood glucose levels. - Choice C is beneficial for managing diabetes but not as critical as blood glucose monitoring. - Choice D, following a low-carb diet, can be helpful but may not be the most important factor in managing the condition.

Correct Answer: A

Rationale: The correct answer is A. Assessing serum creatinine levels and GFR is crucial in monitoring kidney function in CKD patients. These tests provide information on the kidney's ability to filter waste products from the blood. Monitoring these levels helps in determining the stage of CKD and adjusting treatment plans accordingly. Blood glucose levels (B) are important in diabetes management but not the priority in CKD. Hemoglobin levels (C) are important for anemia assessment in CKD but not as critical as kidney function. Potassium levels (D) are important to monitor in CKD, but assessing kidney function takes precedence.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Assessing the communication method preferred by the patient is crucial as it allows the nurse to tailor the communication approach to the patient's needs. 2. By understanding the patient's preferred communication method, the nurse can ensure effective and respectful communication. 3. This approach promotes patient-centered care and fosters a positive therapeutic relationship. 4. Avoiding facial expressions and hand gestures (B) can hinder communication and may not align with the patient's preferences. 5. Requesting a sign language interpreter (C) may be necessary for some patients, but assessing the patient's preferred method should be the initial step. 6. Speaking loudly and with exaggerated facial movement (D) can be ineffective and may not be the patient's preferred method of communication.

Correct Answer: A

Rationale: The correct answer is A: Body systems. This type of assessment promotes critical thinking by organizing data systematically based on different body systems, allowing for clustering of similar data and identification of patterns. Comprehensive assessments (B) may include body systems but lack the focused approach of promoting critical thinking. Head to toe assessments (C) are systematic but may not encourage clustering of data. Emergency assessments (D) prioritize immediate interventions rather than promoting critical thinking or clustering of data.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it helps to reverse the symptoms quickly and prevent further complications. Administering corticosteroids (B) may be considered later for long-term management, but epinephrine is the immediate priority. Administering oxygen (C) may help with respiratory distress but does not address the underlying allergic reaction. Applying a cold compress (D) may provide temporary relief for local reactions but is not effective for a severe systemic allergic reaction.

Correct Answer: A

Rationale: The correct answer is A: Administer thrombolytics. Thrombolytics help dissolve blood clots causing the stroke, restoring blood flow to the brain. This intervention is time-sensitive to prevent further brain damage. Administering aspirin (B) is important but not the priority over thrombolytics. Performing an ECG (C) assesses heart function, not the immediate intervention for stroke. Administering corticosteroids (D) is not indicated in acute stroke management.