How should a nurse document a mass in the foot causing difficulty walking?

Correct Answer: D

Rationale: The correct answer is D: Morton's neuroma. This condition typically presents as a mass in the foot causing pain and difficulty walking. The nurse should document it as Morton's neuroma because it specifically refers to a benign growth of nerve tissue between the toes. Plantar fasciitis (A) is inflammation of the tissue on the bottom of the foot, not a mass. Hallux valgus (B) is a bunion deformity of the big toe joint. Hammertoe (C) is a deformity of the toe joints. Therefore, the correct choice is D as it aligns with the description of a mass causing difficulty walking.

Correct Answer: A

Rationale: The correct answer is A: Administer fluids. In hypovolemic shock, the primary issue is a lack of circulating blood volume. Administering fluids helps to restore blood volume and improve perfusion to vital organs, addressing the underlying cause of shock. Vasopressors (B) are used in distributive shock, sodium bicarbonate (C) is used for metabolic acidosis, and corticosteroids (D) are typically not indicated in hypovolemic shock. Administering fluids is the most important intervention to stabilize the client's condition in hypovolemic shock.

Correct Answer: A

Rationale: The correct answer is A. Assessing serum creatinine levels and GFR is crucial in monitoring kidney function in CKD patients. These tests provide information on the kidney's ability to filter waste products from the blood. Monitoring these levels helps in determining the stage of CKD and adjusting treatment plans accordingly. Blood glucose levels (B) are important in diabetes management but not the priority in CKD. Hemoglobin levels (C) are important for anemia assessment in CKD but not as critical as kidney function. Potassium levels (D) are important to monitor in CKD, but assessing kidney function takes precedence.

Correct Answer: B

Rationale: The correct answer is B: Increase potassium intake. Potassium helps to lower blood pressure by counteracting the effects of sodium. This dietary change is crucial for managing hypertension. Increasing sodium intake (choice A) is incorrect as it can lead to increased blood pressure. Increasing fiber intake (choice C) is beneficial for overall health but not specifically for hypertension. Increasing alcohol intake (choice D) is harmful and can worsen hypertension. Prioritizing increasing potassium intake is essential for effectively managing hypertension.

Correct Answer: A

Rationale: The correct answer is A because broccoli, oranges, and dark greens are rich in essential nutrients like vitamin C, antioxidants, and phytochemicals that boost the immune system and help prevent diseases. Broccoli contains sulforaphane, which has been shown to have anti-cancer properties. Oranges are high in vitamin C, crucial for immune function. Dark greens like spinach and kale are packed with vitamins and minerals that support overall health. Choice B is incorrect because no single food can cure many diseases. Choice C is incorrect because relying solely on vitamin pills may not provide all the necessary nutrients and benefits of whole foods. Choice D is incorrect as there is no scientific evidence supporting the concept of balancing body molecules through food.

Correct Answer: C

Rationale: The correct answer is C: Assessing the patient's respiratory status. After administering pain medication, especially opioids, it is crucial to monitor the patient's respiratory status due to the risk of respiratory depression. This assessment is a priority because respiratory depression can be life-threatening. Other choices are not as immediate: A, assessing for addiction, can be done but is not as critical at this moment; B, assessing pain level, is important but comes after ensuring the patient's safety; D, assessing for infection, is not directly related to the immediate effects of pain medication.

Correct Answer: D

Rationale: The correct answer is D: To treat human responses. This goal aligns with the nursing profession's focus on addressing the holistic needs of individuals. Nurses aim to understand and manage patients' emotional, physical, and psychological responses to illness or treatment. By treating human responses, nurses can improve overall well-being. A: Providing cost-effective care is important but not a broad goal within nursing. It is a component of efficient healthcare delivery. B: Forming broad nursing diagnoses is a part of the nursing process, not a broad goal in itself. C: Promoting self-care is crucial in nursing practice, but it is more of a specific intervention rather than a broad goal encompassing the entire profession.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. This is crucial for preventing blood clots post-surgery as they help thin the blood and reduce clot formation. Monitoring for arrhythmias (B) is important but not the priority in this case. While encouraging deep breathing (C) and fluid intake (D) are beneficial for post-surgical recovery, they do not directly address the risk of blood clot formation. Administering anticoagulants is the most effective intervention to prevent blood clots in high-risk surgical patients.

Correct Answer: B

Rationale: The correct answer is B, Hepatic encephalopathy. In cirrhosis, the liver is unable to detoxify ammonia, leading to its accumulation and causing neurological symptoms. Monitoring for signs such as confusion, altered mental status, and asterixis is crucial. Acute renal failure (A) is not directly related to cirrhosis but may occur as a complication. Acute pancreatitis (C) is not a typical complication of cirrhosis. COPD (D) is a respiratory condition and not directly associated with cirrhosis.