A nurse is teaching a patient with diabetes about insulin administration. Which of the following actions should the nurse emphasize to the patient?

Correct Answer: D

Rationale: The correct answer is D: Rotate injection sites to prevent lipodystrophy. Rotating injection sites helps prevent the development of lipodystrophy, a condition characterized by the loss of fat tissue at the injection site. This is important for maintaining consistent insulin absorption and reducing the risk of injection site complications. A: Storing insulin at room temperature is generally recommended, but it is not the most critical action for insulin administration. B: Using insulin immediately after drawing it up is not necessary for all types of insulin and may not be feasible in all situations. C: Injecting insulin into the same spot can lead to tissue damage and inconsistent insulin absorption, so it should be avoided.

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: C

Rationale: Rationale: 1. Nursing diagnoses evaluate the response of the whole person to health problems, not just specific organ systems. 2. They focus on the individual's physical, emotional, social, and spiritual well-being. 3. Nursing diagnoses are independent of medical diagnoses and consider the person holistically. 4. Option C aligns with the nursing process and the holistic approach of nursing care. Summary: Option A is incorrect as nursing diagnoses do not solely evaluate the etiology of disease. Option B is incorrect as nursing diagnoses are independent of medical diagnoses. Option D is incorrect as nursing diagnoses focus on the whole person, not just specific organ systems.

Correct Answer: D

Rationale: The correct answer is D: Worsening heart failure. Shortness of breath, fatigue, and leg swelling are common symptoms of heart failure. Monitoring for signs of worsening heart failure, such as increased dyspnea, weight gain, and decreased exercise tolerance, is crucial. Pulmonary embolism (A) presents with sudden chest pain and shortness of breath, not typically associated with chronic heart failure. Renal failure (B) may present with decreased urine output and electrolyte imbalances. Liver failure (C) may present with jaundice and changes in mental status. However, given the symptoms presented by the patient, monitoring for worsening heart failure is the most appropriate choice.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates a rapid succession of loosely associated thoughts, typical of flight of ideas. The statement transitions from discussing a pill to the color red, then red velvet, and finally to a baby's bottom. This rapid and disjointed flow of thoughts is characteristic of flight of ideas, a symptom commonly seen in manic episodes of bipolar disorder. Choices A, B, and D do not exhibit the same level of rapid and tangential thoughts as choice C, making them incorrect.

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: Respiratory failure. For a patient with chronic asthma, the priority complication to monitor for is respiratory failure as it can be life-threatening. Asthma is a chronic respiratory condition that can lead to severe bronchoconstriction and impaired gas exchange, potentially resulting in respiratory failure. Monitoring for signs such as increased respiratory rate, use of accessory muscles, decreased oxygen saturation, and altered mental status is crucial. Pneumothorax (A) is a possible complication but less common in chronic asthma. Hyperglycemia (B) and chronic renal failure (D) are not directly related to asthma and are not the primary complications to monitor for in this case.

Correct Answer: B

Rationale: The correct answer is B: Swelling in the legs and shortness of breath. In heart failure, fluid can build up in the body causing swelling, particularly in the legs. Shortness of breath is a common symptom due to fluid accumulation in the lungs. Increased urine output and weight loss (A) are not indicative of worsening heart failure as they suggest fluid loss. Decreased blood pressure and dizziness (C) can be seen in other conditions like dehydration. Fatigue and constipation (D) are not specific signs of heart failure worsening.

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.