A nurse is teaching a patient with hypertension about dietary modifications. Which of the following statements by the patient indicates proper understanding?

Correct Answer: B

Rationale: Correct Answer: B Rationale: Limiting alcohol intake reduces blood pressure. Reducing sodium intake also helps manage hypertension. Alcohol can increase blood pressure, while sodium can lead to fluid retention. The patient's statement shows understanding of the importance of both factors in managing hypertension. Other Choices: A: Increasing sodium intake worsens fluid retention and hypertension. C: Processed foods are often high in sodium and unhealthy fats, worsening hypertension. D: Reducing exercise can lead to weight gain and increased blood pressure, contrary to managing hypertension.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. During an acute asthma attack, the priority is to open the airways quickly to improve breathing. Bronchodilators work rapidly to dilate the constricted airways, providing immediate relief. Corticosteroids are used for long-term management and take time to be effective. Administering morphine is not recommended as it can depress the respiratory system. Performing an ECG is not necessary in the acute management of an asthma attack.

Correct Answer: A

Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.

Correct Answer: D

Rationale: The correct answer is D: Atelectasis and pneumonia. Following abdominal surgery, patients are at risk for atelectasis (lung collapse) due to shallow breathing and pneumonia due to impaired lung function. A nurse should monitor for signs such as decreased oxygen saturation, increased respiratory rate, and crackles on auscultation. Wound infection (A) is a common post-operative complication but not specific to abdominal surgery. Hyperglycemia (B) may occur due to stress response but is not directly related to abdominal surgery. Dehydration (C) is a concern post-operatively, but respiratory complications like atelectasis and pneumonia are higher priority due to potential life-threatening consequences.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. When caring for a client with suspected hypoglycemia, the first priority is to raise their blood sugar levels quickly to prevent potential complications such as seizures or loss of consciousness. Administering glucose helps to rapidly increase blood sugar levels and alleviate symptoms. The other choices (B: Administer insulin, C: Place the client in a supine position, D: Administer IV fluids) are incorrect because administering insulin can further lower blood sugar levels, placing the client in a supine position may not address the immediate issue of low blood sugar, and administering IV fluids does not directly address the hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A, administer insulin, because hyperglycemia indicates high blood sugar levels which can be effectively lowered by administering insulin. Insulin helps to move glucose from the blood into cells for energy production. Administering fluids (B) can be helpful for dehydration, but it does not directly address the high blood sugar levels. Encouraging activity (C) may help lower blood sugar levels over time, but in the immediate situation, administering insulin is more effective. Encouraging deep breathing (D) does not directly address hyperglycemia and would not be the appropriate first step in managing this condition.

Correct Answer: A

Rationale: Correct Answer: A (Iron, folic acid, and B12) Rationale: 1. Iron: Renal failure patients often have anemia due to decreased erythropoietin production. 2. Folic acid and B12: Important for red blood cell production and maturation. 3. Corrects underlying causes of anemia in renal failure patients. Summary: B: Increasing protein doesn't directly address anemia in renal failure. C: Vitamin D and calcium are not primary treatments for anemia in renal failure. D: Calcium and folic acid alone do not address the specific deficiencies seen in renal failure anemia.

Correct Answer: A

Rationale: The correct answer is A (3 years old) because the Nipissing District Developmental Screen is specifically designed for children aged 1 month to 6 years to assess their developmental milestones. It focuses on various areas of development appropriate for this age group, such as motor skills, language, social interaction, and cognitive abilities. Using this tool with a 3-year-old child allows for early identification of potential developmental delays or concerns. Incorrect choices: B (16 years old) - The Nipissing District Developmental Screen is not intended for children above 6 years old. C (8 years old with a developmental delay) - The tool is primarily for early screening, not for children already identified with developmental delays. D (Having difficulty with gross motor skills) - While this child may benefit from assessment, the Nipissing Screen is a comprehensive tool for overall development, not just specific skill deficits.

Correct Answer: D

Rationale: The correct answer is D: Administer corticosteroids. In a client with chest pain and a history of myocardial infarction, the first priority is to address potential inflammation in the myocardium. Corticosteroids help reduce inflammation and stabilize the myocardium, which is crucial in preventing further damage post-myocardial infarction. Administering nitroglycerin (A) is important for vasodilation, but it is typically used after corticosteroids. Morphine (B) and analgesics (C) may provide pain relief but do not address the underlying inflammation. Administering corticosteroids is the most appropriate first step to manage myocardial inflammation and protect the heart tissue.