A patient often seems to have difficulty coming up with the right words. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up was so full that I decided to take the stairs.' The nurse will note on his chart that he is using or experiencing:

Correct Answer: C

Rationale: The correct answer is C: Circumlocution. This patient is using circumlocution, which is a communication strategy where a person describes something in a roundabout way instead of using the specific word. In this case, the patient is describing an elevator as "the thing that you step into that goes up." This is a common feature of language difficulties seen in conditions like aphasia. A: Blocking is when a person suddenly stops speaking in the middle of a sentence due to an inability to recall a word, which is not happening in this scenario. B: Neologism is the creation of new words or phrases, which is not evident here. D: Circumstantiality is a speech pattern where the person includes unnecessary details and goes off on tangents, which is not demonstrated in the patient's response.

Correct Answer: A

Rationale: The correct answer is A: Jaundice. In chronic liver disease, the liver is unable to properly process bilirubin, leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. It is a common complication of liver disease and indicates impaired liver function. Anemia (choice B) may occur in liver disease, but it is not the primary complication. Hyperglycemia (choice C) and hypoglycemia (choice D) are more commonly associated with diabetes or pancreatic disorders, rather than chronic liver disease. Therefore, monitoring for jaundice is crucial in the care of a patient with chronic liver disease.

Correct Answer: A

Rationale: The correct answer is A: Hypertensive crisis. The nurse should be most concerned about this option because the patient has a history of hypertension and is experiencing new onset symptoms such as headaches, nausea, and dizziness, which could indicate a sudden and severe increase in blood pressure. This condition, if left untreated, can lead to serious complications such as stroke or heart attack. Summary: - B: Migraine headache is unlikely as the symptoms described are not typical of a migraine. - C: Benign positional vertigo is unlikely as it does not explain the presence of headaches and nausea. - D: Tension headache is less concerning compared to hypertensive crisis, given the patient's history of hypertension and the severity of symptoms.

Correct Answer: A

Rationale: The correct answer is A: Limiting sodium intake. This is crucial for a patient with hypertension as excess sodium can lead to increased blood pressure. Sodium intake should be limited to lower the risk of cardiovascular complications. B: Increasing potassium intake is beneficial, but not as critical as limiting sodium for hypertension management. C: Increasing fluid intake may or may not be necessary depending on the patient's condition, but it is not as crucial as limiting sodium for hypertension management. D: Consuming more caffeine can actually elevate blood pressure, so it is not recommended for patients with hypertension.

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Asking "How do you feel today?" directly addresses the patient's emotional state. 2. Assessing affect involves understanding the patient's emotional response or mood. 3. This open-ended question encourages the patient to express their feelings. 4. It allows the nurse to gain insight into the patient's emotional well-being. 5. Options B, C, and D focus on different aspects like memory, medication effectiveness, and functional ability, not directly related to assessing affect.

Correct Answer: A

Rationale: The correct answer is A. Regularly checking blood glucose levels is crucial for diabetic patients to monitor their condition and adjust treatment as needed. This helps in managing blood sugar levels effectively and preventing complications. Choice B is incorrect because stopping insulin abruptly can lead to dangerous fluctuations in blood sugar levels. Choice C is incorrect because while exercise is important for diabetic patients, vigorous exercise every day may not be suitable for everyone and should be discussed with healthcare providers. Choice D is incorrect as carbohydrates are an essential source of energy and nutrients for the body. Diabetic patients can still consume carbohydrates in controlled portions as part of a balanced diet.

Correct Answer: B

Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This is the best action because it allows the nurse to assess for potential underlying issues such as pneumothorax or pleural effusion which could be causing the respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the chest. Choice A is incorrect because simply counting respirations does not provide immediate information on the cause of distress. Choice C is incorrect as inspecting for masses and bleeding does not directly address the urgency of the situation. Choice D is incorrect as waiting for a chest x-ray would delay necessary interventions in a critical situation.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation to prevent complications. Early ambulation after abdominal surgery helps prevent postoperative complications like deep vein thrombosis and pneumonia. It promotes circulation, aids in bowel function, and reduces the risk of atelectasis. Encouraging the patient to move also helps with pain management and overall recovery. Choice A: Administering antiemetics as needed. While addressing nausea and vomiting is important, it is not the top priority in this case. Choice C: Providing wound care and dressing changes. Wound care is crucial, but ensuring early ambulation takes precedence to prevent complications. Choice D: Monitoring for signs of infection. While monitoring for infection is essential, promoting early ambulation is a proactive measure to prevent various complications and enhance recovery.

Correct Answer: C

Rationale: The correct answer is C because prevention emphasizes the importance of personal behavior in maintaining health. It highlights the role of individual choices in preventing diseases and promoting well-being. A is incorrect because prevention focuses on proactive measures rather than treating external factors. B is incorrect as it contradicts the importance of prevention in reducing preventable deaths. D is incorrect because prevention is about avoiding health issues before they occur, not treating them after they have developed.