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: C

Rationale: The correct answer is C because it reflects empathy by acknowledging the mother's feelings without judgment or personal bias. The nurse shows understanding and compassion by recognizing the difficulty of the situation. Incorrect answer A lacks empathy as it simply restates the mother's feeling without demonstrating understanding. Answer B also lacks empathy as it focuses on the boyfriend's actions rather than the mother's feelings. Answer D shows some empathy by acknowledging the difficulty but fails to address the mother's emotional state directly. In summary, answer C is correct because it shows empathy by acknowledging the mother's emotions and validating her experience without judgment or redirection.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.

Correct Answer: B

Rationale: The correct answer is B: increased fibrinogen. Heparin therapy works by inhibiting clot formation by enhancing the activity of antithrombin III, which leads to decreased levels of fibrinogen. Therefore, an increase in fibrinogen levels would indicate a positive response to Heparin therapy. Incorrect choices: A: increased platelet count - Heparin therapy does not typically affect platelet count, so an increase in platelet count would not indicate a positive response to Heparin therapy. C: decreased fibrin split products - Decreased fibrin split products may not necessarily indicate a positive response to Heparin therapy, as other factors can also influence their levels. D: decreased bleeding - While decreased bleeding can be a positive outcome of Heparin therapy, it is not a direct assessment finding that indicates a positive response to the therapy.

Correct Answer: A

Rationale: The correct first action when a client develops a fever after surgery is to administer antipyretics (A). Fever post-surgery can indicate infection, and antipyretics help lower the body temperature. Administering pain medications (B) may mask the fever's underlying cause. Providing fluids (C) is essential but not the priority. Providing wound care (D) is important but comes after addressing the fever. Administering antipyretics promptly helps manage the fever and allows for further assessment and intervention if needed.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. This is the first action because epinephrine is the primary treatment for anaphylaxis, a severe allergic reaction that can be life-threatening. It works quickly to reverse the symptoms by constricting blood vessels and opening airways. Administering epinephrine promptly can prevent progression to severe complications such as respiratory distress or cardiovascular collapse. Placing the client in a supine position and administering oxygen (B) may be necessary but should not delay the administration of epinephrine. Administering fluids (C) may help maintain blood pressure but is not the priority in the acute phase of anaphylaxis. Antihistamines (D) are not effective for treating the severe symptoms of anaphylaxis and should not be the first-line treatment.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. In hypoglycemia, the priority is to raise the low blood sugar levels quickly. Administering glucose is the most direct and effective way to do so. Glucose will rapidly increase the blood sugar levels and help the client recover from hypoglycemia. Administering insulin (B) would further lower blood sugar levels. Administering glucagon (C) is used for severe hypoglycemia when the client is unconscious. Encouraging deep breathing (D) is not effective in treating hypoglycemia and does not address the immediate need to raise blood sugar levels.

Correct Answer: A

Rationale: The correct answer is A: "Smoking increases the risk of complications during surgery." Smoking constricts blood vessels, reduces oxygen levels, and impairs the body's ability to heal. This can lead to increased risks of infections, delayed wound healing, and other complications during and after surgery. Choice B is vague and does not address the specific risks associated with smoking. Choice C is too general and does not emphasize the immediate risks related to surgery. Choice D implies a benefit after surgery rather than focusing on the risks associated with smoking before surgery.

Correct Answer: A

Rationale: The correct answer is A because memory loss after a fall can be indicative of a more serious issue like a head injury or neurological problem. A complete mental health examination by the nurse can help assess the extent of memory loss, identify potential causes, and determine appropriate interventions. Referring to a psychometrician (choice B) may not address the immediate health concern. Integrating the mental health examination into history taking and physical examination (choice C) is important but may not be as thorough as a complete mental health examination by a professional. Reassuring the wife that memory loss is normal (choice D) may lead to overlooking a potentially serious health issue.