A nurse is providing education to a patient about managing hypertension. Which of the following statements by the patient indicates the need for further education?

Correct Answer: D

Rationale: The correct answer is D because stopping medication once blood pressure returns to normal can lead to a relapse of hypertension. Step 1: Educate the patient that hypertension is a chronic condition requiring long-term management. Step 2: Explain the importance of continuing medication even when blood pressure is controlled. Step 3: Emphasize the risks of stopping medication abruptly. Other choices are incorrect because they promote positive behaviors for hypertension management: A: Monitoring blood pressure is essential. B: Taking medication consistently is crucial. C: Avoiding high-sodium foods helps control blood pressure.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.

Correct Answer: C

Rationale: The correct answer is C: Placing the client on their back. This is the priority because it helps optimize the client's breathing mechanics by maximizing lung expansion. By positioning the client on their back, it allows for better oxygenation and ventilation. Administering oxygen (A) and albuterol (B) can be important interventions but positioning comes first. Placing the client on their back also helps prevent aspiration and facilitates airway clearance. Encouraging deep breathing (D) is beneficial, but if the client is in respiratory distress, ensuring proper positioning takes precedence over deep breathing exercises.

Correct Answer: A

Rationale: The correct answer is A because it helps differentiate between orthopnea (difficulty breathing when lying down) and paroxysmal nocturnal dyspnea (sudden awakening due to difficulty breathing). By asking about worsening symptoms when lying down, the nurse can assess if the patient has orthopnea, a classic symptom of heart failure. Choices B, C, and D are incorrect because they do not specifically target the nighttime breathing difficulty associated with heart failure.

Correct Answer: B

Rationale: The correct answer is B: Monitor for arrhythmias. This is because in a client showing signs of shock after surgery, the priority is to assess for any cardiac complications such as arrhythmias, which can be life-threatening. Monitoring for arrhythmias allows prompt identification and intervention. Administering a blood transfusion (A) may be necessary in some cases of shock but is not the first intervention. Administering oxygen (C) may also be necessary, but addressing cardiac complications takes precedence. Encouraging deep breathing (D) is not a priority in managing shock-related complications.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. The nurse should address the client's immediate symptom of severe headache to provide comfort and assess the severity of the condition. Pain relief can help decrease anxiety and prevent complications. Monitoring vital signs (B) is important but treating the symptom should take priority. Monitoring ECG (C) is not necessary for a headache presentation. Administering insulin (D) is not indicated for a client presenting with a severe headache.

Correct Answer: C

Rationale: The correct answer is C because validating the data by asking a colleague to listen to the breath sounds helps to ensure accuracy and reliability. It allows for a second opinion to confirm the nurse's assessment and prevents any potential misinterpretation. This collaborative approach promotes patient safety and quality care. Choices A and D are incorrect as they do not address the immediate need for validation and may delay appropriate intervention. Choice B is also incorrect as it does not ensure the accuracy of the assessment and may lead to miscommunication or incorrect treatment decisions.

Correct Answer: D

Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.

Correct Answer: B

Rationale: The correct answer is A: Eggs. Eggs are considered a complete protein because they contain all 9 essential amino acids required by the human body. This makes them a high-quality protein source. Corn (B), peanuts (C), and sunflower seeds (D) are not complete proteins as they lack one or more of the essential amino acids. Corn is deficient in lysine, peanuts are deficient in methionine, and sunflower seeds are deficient in lysine. Therefore, only eggs provide all the essential amino acids necessary for optimal health and proper bodily functions.