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: B

Rationale: The correct assessment is B because providing consistent information indicates reliability. Drug abuse history (A) does not necessarily mean the patient is unreliable. Smiling (C) is not a reliable indicator. Refusal to answer specific questions (D) does not negate overall reliability.

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: Step 1: Administering IV antibiotics is important for treating infections, but in this case, the focus is on addressing the pain associated with the deep wound infection. Step 2: Administering pain relief helps improve the client's comfort and quality of life while the infection is being treated. Step 3: Changing the dressing is essential for wound care but does not directly address the client's pain from the infection. Step 4: Performing a CT scan may be necessary to assess the extent of the infection, but it does not directly provide immediate relief for the client's pain. Summary: Administering pain relief is the most appropriate intervention as it directly addresses the client's symptoms and improves their comfort level during the treatment of the deep wound infection.

Correct Answer: A

Rationale: The correct answer is A: Neutropenia. Neutropenia is a common side effect of chemotherapy where there is a decrease in neutrophil count, increasing the risk of infections. Monitoring for neutropenia is crucial to prevent serious infections and sepsis in chemotherapy patients. Hyperkalemia (B), chronic pain (C), and hypertension (D) are not direct complications of chemotherapy and do not pose immediate life-threatening risks to patients undergoing chemotherapy. Monitoring for neutropenia takes precedence due to the potential for life-threatening infections in immunocompromised patients.

Correct Answer: C

Rationale: The correct answer is C: Apply an airtight dressing. This is the first priority because it helps prevent air from entering the chest cavity, which can cause a tension pneumothorax. A tension pneumothorax can rapidly lead to respiratory distress and cardiac arrest. Applying an airtight dressing helps stabilize the condition until further medical intervention can be provided. Incorrect choices: A: Performing needle decompression is not the first priority as it is indicated for a tension pneumothorax once it has developed, not as a preventive measure. B: Applying a sterile dressing is important but not the first priority when dealing with a gunshot wound to the chest as sealing the wound to prevent air entry is more critical. D: Monitoring the client's ECG is not the first priority in this situation as addressing the potential tension pneumothorax takes precedence over monitoring the client's heart rhythm.

Correct Answer: C

Rationale: Step 1: Hypertension is often worsened by high sodium intake. Step 2: Decreasing sodium intake helps lower blood pressure. Step 3: This dietary change aligns with hypertension management. Step 4: Increasing processed foods (A), saturated fats (D), or potassium intake (B) do not directly address the issue of high sodium intake and may even exacerbate hypertension.

Correct Answer: B

Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. This is because in hypoglycemia, the patient's blood sugar levels are low and need to be raised quickly to avoid serious complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (choice A) would further lower blood sugar levels, monitoring without intervention (choice C) could lead to worsening symptoms, and administering an oral hypoglycemic agent (choice D) may not act quickly enough to raise blood sugar levels in an emergency situation.

Correct Answer: C

Rationale: The correct answer is C: Dizziness and shakiness. This indicates hypoglycemia, a potential side effect of insulin therapy. Dizziness and shakiness are classic signs of low blood sugar levels, which can be dangerous if left untreated. Headache and blurred vision (Option A) can occur with high blood sugar. Increased thirst and urination (Option B) are symptoms of hyperglycemia. Dry mouth and skin (Option D) are not immediate concerns related to insulin therapy.