A nurse is preparing to document a patient whohas chest pain. Which information is critical for the nurse to include?

Correct Answer: D

Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.

Correct Answer: C

Rationale: The correct answer is C: Weight does not change. When a patient's energy requirements are completely met by kcal intake, their weight should remain stable as there is a balance between energy intake and expenditure. This indicates that the body is receiving adequate energy for its needs, leading to weight maintenance. A: Weight increases - This would indicate an excess of energy intake over expenditure, leading to weight gain. B: Weight decreases - This would indicate a deficit in energy intake compared to expenditure, resulting in weight loss. D: Weight fluctuates daily - Daily weight fluctuations are normal and can be influenced by factors like hydration levels, food intake, and exercise, but a stable weight over time indicates a balance between energy intake and expenditure.

Correct Answer: D

Rationale: The correct answer is D: Deficiencies occur when fat intake falls below 10% of daily nutrition. Rationale: 1. Fat is essential for absorption of fat-soluble vitamins (A, D, E, K) and for maintaining healthy cell membranes. 2. Fat provides essential fatty acids (omega-3, omega-6) crucial for brain function and inflammation regulation. 3. Adequate fat intake prevents deficiencies like dry skin, poor wound healing, and hormonal imbalances. 4. A low-fat diet should still include at least 10% of daily nutrition from healthy fats for optimal health. Summary: A: Cholesterol intake is important but not the primary focus for a low-fat diet. B: Fats are significant for health, and extreme low-fat diets can lead to deficiencies. C: While some fats are from external sources, the body needs a minimum amount for proper functioning.

Correct Answer: D

Rationale: The correct answer is D because breast milk or formula is recommended for the first 4 to 6 months as it provides essential nutrients for infant growth and development. Choosing A, B, or C is incorrect as they pose health risks to infants - corn syrup is not necessary, cow's milk is not suitable for infants, and honey can cause botulism in infants under 1 year old. Breast milk or formula is the safest and most nutritionally balanced option for infants in the first few months of life.

Correct Answer: D

Rationale: The correct answer is D because neurogenic dysphagia is caused by neurological conditions affecting swallowing function, such as a stroke. In a stroke, damage to the brain can impair the coordination of swallowing muscles, leading to dysphagia. Choice A is incorrect because benign peptic stricture is a narrowing of the esophagus due to chronic acid reflux, not a neurological issue. Choice B is incorrect because muscular dystrophy is a genetic disorder that affects muscle strength and does not directly impact the neurological control of swallowing. Choice C is incorrect because myasthenia gravis is an autoimmune disorder that affects neuromuscular transmission but is not typically associated with neurogenic dysphagia.