A patient is experiencing tingling sensations in her feet and has also noticed that her tongue has become very red and painful. The nurse suspects that she has:

Correct Answer: B

Rationale: The correct answer is B: Pernicious anemia. This condition is characterized by a deficiency in vitamin B12, leading to neurological symptoms like tingling sensations in the feet (peripheral neuropathy) and glossitis, causing the tongue to become red and painful. Polycythemia (A) is an increase in red blood cell mass, not related to the symptoms described. Micronucleus anemia (C) is not a recognized medical condition. Iron-deficiency anemia (D) can lead to symptoms like fatigue and pallor, but not typically tingling sensations in the feet or glossitis.

Correct Answer: A

Rationale: The correct answer is A: Cleanse and dress the wound. This intervention is essential as it helps prevent infection, promotes healing, and maintains a moist wound environment. Cleansing removes debris and bacteria, while dressing protects the wound from external contaminants. Administering antibiotics (choice B) is not the initial intervention for an open wound. Placing a sterile dressing (choice C) is important, but cleansing the wound first is crucial. Ensuring wound care is sterile (choice D) is important, but the primary focus should be on cleansing and dressing the wound.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis. Patients with a history of stroke are at an increased risk of developing deep vein thrombosis due to immobility and vascular damage. This complication can lead to serious consequences, such as pulmonary embolism. Monitoring for signs of deep vein thrombosis, such as leg swelling and pain, is crucial for early detection and intervention. Severe dehydration (A), liver failure (C), and pulmonary embolism (D) are less likely complications in a patient with a history of stroke compared to deep vein thrombosis.

Correct Answer: B

Rationale: The correct answer is B: a set of rules. Novice nurses rely on established guidelines and protocols to make decisions as they lack the experience to rely solely on intuition or journal articles. Rules provide structure and consistency in decision-making, reducing the margin of error. Intuition (choice A) may not be reliable without prior experience. Journal articles (choice C) can be overwhelming and may not directly apply to the specific situation. Advice from supervisors (choice D) can be helpful but may not always be readily available, and it's important for novice nurses to develop their own decision-making skills.

Correct Answer: B

Rationale: The correct answer is B: Check the room temperature. This is important because extreme temperatures can affect the accuracy of bowel sound assessment. Cold temperatures can cause vasoconstriction, leading to decreased bowel sounds, while warm temperatures can lead to increased sounds due to increased blood flow. Choice A (Clean the stethoscope before use) is important for infection control but not directly related to ensuring accurate bowel sound assessment. Choice C (Place the stethoscope directly on the skin) is incorrect as bowel sounds are auscultated through clothing. Choice D (Use a hand sanitizer after use) is important for hand hygiene but not necessary before using the stethoscope for bowel sounds.

Correct Answer: C

Rationale: The correct answer is C because stopping insulin when blood sugar is normal can lead to hyperglycemia. Choice A shows understanding of managing diabetes. Choice B indicates monitoring blood sugar, crucial for diabetes management. Choice D demonstrates adherence to medication schedule, essential for controlling blood sugar levels. Stopping insulin prematurely can disrupt the balance and result in complications.

Correct Answer: A

Rationale: The correct answer is A (Broccoli, oranges, dark greens) because these foods are high in soluble fiber, antioxidants, and plant sterols which are known to help lower cholesterol levels. Broccoli contains fiber that binds to cholesterol in the gut, oranges are rich in vitamin C and fiber, and dark greens like spinach and kale are packed with antioxidants and fiber. Option B (Fiber-rich foods) is partially correct as fiber can help reduce cholesterol levels, but it is not as specific as the foods mentioned in option A. Option C (Increase intake of omega-3 fatty acids) is not directly related to lowering cholesterol, although omega-3s have other health benefits. Option D (Eliminate fat-rich foods) is not ideal as not all fats are bad for cholesterol, and some healthy fats like those found in avocados and nuts can actually improve cholesterol levels.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client is experiencing respiratory distress, the priority intervention is to open up the airways to improve breathing. Bronchodilators help relax and widen the airways, making it easier for the client to breathe. This intervention addresses the immediate need for improved respiratory function. Administering corticosteroids (choices B and C) may be beneficial in some cases but is not the priority in acute respiratory distress. Monitoring respiratory rate (choice D) is important but does not directly address the underlying issue of airway constriction in respiratory distress.

Correct Answer: C

Rationale: The most important goal for a nurse when implementing care for a patient with a chronic illness is to prevent future complications (Choice C). This is because chronic illnesses are long-term conditions that require ongoing management to minimize the risk of complications and improve the patient's quality of life. By preventing future complications, the nurse helps maintain the patient's health and prevents the progression of the disease. Providing emotional support (Choice D) is important but not the most crucial goal in this context. While reducing symptoms (Choice B) is important, preventing future complications takes precedence as it addresses the underlying cause of the illness. Curing the disease (Choice A) may not always be feasible for chronic illnesses, making prevention of complications a more realistic and essential goal.