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

Correct Answer: D

Rationale: The correct answer is D: Hyperglycemia. In diabetes, hyperglycemia occurs when blood sugar levels are too high. This can lead to various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. Monitoring for hyperglycemia is crucial to prevent these serious complications. A: Hypoglycemia is low blood sugar and can also occur in diabetes, but it is not the primary complication to monitor for in this case. B: Hyperkalemia is high potassium levels and is not a common complication of diabetes unless there are other underlying issues. C: Hypotension is low blood pressure, which can be a complication of diabetes but is not as directly related to glucose management as hyperglycemia. In summary, monitoring for hyperglycemia is essential in diabetes care to prevent serious complications associated with high blood sugar levels.

Correct Answer: C

Rationale: The correct answer is C: Give him the Four Unrelated Words Test. This is the best way to assess new memory because it is a standardized test specifically designed to evaluate a patient's ability to form new memories. The test involves presenting the patient with four unrelated words and then asking them to recall those words after a delay. This test is reliable, valid, and widely used in clinical settings to assess new memory formation. Other choices are incorrect because: A: Administering the FACT test is not the best way to assess new memory as it is not specifically designed for this purpose. B: Asking the patient to describe his first job does not directly evaluate new memory formation and may not provide a standardized assessment. D: Asking the patient to describe the last TV show he watched does not focus on new memory and is not a standardized way to assess memory function.

Correct Answer: D

Rationale: The correct answer is D because avoiding physical activity to prevent joint strain is not recommended for managing osteoarthritis. Exercise is crucial for strengthening joints and improving flexibility. Choice A is correct as heat or cold therapy can help relieve joint pain. Choice B is correct as taking pain medication regularly can help manage symptoms. Choice C is correct as regular exercise is important for maintaining joint health. In summary, avoiding physical activity is not a recommended approach for managing osteoarthritis, unlike the other choices which are beneficial for the condition.

Correct Answer: B

Rationale: The correct answer is B: Jaundice. In chronic liver disease, impaired liver function leads to the accumulation of bilirubin in the blood, causing jaundice. Jaundice is a common complication seen in patients with liver disease. Anemia (choice A) may occur in liver disease but is not as specific as jaundice. Hypertension (choice C) is not a direct complication of liver disease. Hypoglycemia (choice D) is more commonly associated with pancreatic disorders, not liver disease. Therefore, monitoring for jaundice is crucial in patients with chronic liver disease.

Correct Answer: C

Rationale: The correct answer is C because it indicates that the information was provided directly by the patient and is based on their perception or feeling. Subjective data is based on the patient's experiences and cannot be observed or measured by others. Choices A, B, and D are all objective data as they can be observed or measured by healthcare providers. Choice A describes a visible characteristic of the skin, choice B indicates absence of observable lesions, and choice D reports an observed lesion on a specific location of the skin. Therefore, choice C is the only option that reflects subjective data about the patient's skin.

Correct Answer: C

Rationale: The correct answer is C: Abnormal laboratory values. Second-level priority problems are those that are important to the patient's health but may not be life-threatening. Abnormal laboratory values fall into this category as they indicate an underlying health issue that needs attention. Low self-esteem (A) and lack of knowledge (B) are typically considered third-level priority problems, as they do not pose an immediate threat to the patient's health. Severely abnormal vital signs (D) are first-level priority problems, as they indicate an acute and potentially life-threatening situation that requires immediate intervention. Therefore, the correct answer is C as it aligns with the definition of second-level priority problems.

Correct Answer: C

Rationale: The correct answer is C, hypercapnia. In COPD, impaired lung function leads to inadequate oxygen exchange, causing increased carbon dioxide levels in the blood (hypercapnia). This can result in respiratory acidosis and further exacerbate respiratory distress. Monitoring for hypercapnia is crucial in COPD management to prevent respiratory failure. Incorrect choices: A: Pulmonary embolism - While patients with COPD are at increased risk for blood clots, pulmonary embolism is not a direct complication of COPD. B: Pneumothorax - Although individuals with COPD may develop pneumothorax due to weakened lung tissue, it is not a common complication. D: Asthma attack - Asthma and COPD are distinct conditions with different pathophysiology. Asthma attacks are not a typical complication of COPD.

Correct Answer: A

Rationale: The correct answer is A because when a patient is experiencing significant shortness of breath, the nurse should initially focus on assessing the areas directly related to the presenting problem to address the immediate issue. This approach allows for prompt intervention and treatment of the patient's acute condition. Once the patient's respiratory distress is managed, the nurse can then proceed with a complete assessment to identify any underlying or additional health issues. This stepwise approach ensures that the patient's urgent needs are met first before conducting a comprehensive assessment. Choices B, C, and D are incorrect because: B: Performing a mini-database by only examining body areas directly related to the problem may not provide a comprehensive understanding of the patient's condition and could overlook other potential health issues. C: Dismissing significant shortness of breath as a normal finding and proceeding with an abdominal assessment is inappropriate and could delay necessary interventions for the respiratory distress. D: Examining the entire body to determine if the problem is linked to something else is inefficient and

Correct Answer: D

Rationale: The correct answer is D because the patient's behavior of not making eye contact and looking down can be a sign of active listening and respect in some cultures, including many First Nations cultures. This behavior may indicate that the patient is focusing on what the nurse is saying and showing attentiveness. Making eye contact may be considered disrespectful or challenging in some cultures, so the lack of eye contact does not necessarily mean the patient has something to hide, is ashamed, or is nervous. Choice A assumes the patient is nervous or embarrassed without evidence. Choice B is an assumption without any basis, and choice C does not consider cultural differences in communication styles.