The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

Correct Answer: A

Rationale: The correct answer is A because when a patient is experiencing significant shortness of breath, the nurse should initially focus on assessing the areas directly related to the presenting problem to address the immediate issue. This approach allows for prompt intervention and treatment of the patient's acute condition. Once the patient's respiratory distress is managed, the nurse can then proceed with a complete assessment to identify any underlying or additional health issues. This stepwise approach ensures that the patient's urgent needs are met first before conducting a comprehensive assessment. Choices B, C, and D are incorrect because: B: Performing a mini-database by only examining body areas directly related to the problem may not provide a comprehensive understanding of the patient's condition and could overlook other potential health issues. C: Dismissing significant shortness of breath as a normal finding and proceeding with an abdominal assessment is inappropriate and could delay necessary interventions for the respiratory distress. D: Examining the entire body to determine if the problem is linked to something else is inefficient and

Correct Answer: A

Rationale: The correct answer is A: Chronic liver disease. Patients with a history of alcohol abuse are at increased risk for chronic liver disease due to the toxic effects of alcohol on the liver. Alcohol can lead to fatty liver, alcoholic hepatitis, cirrhosis, and liver cancer. The liver plays a crucial role in metabolizing alcohol, and excessive alcohol consumption can overwhelm the liver's ability to detoxify the body. Chronic kidney disease (B), pulmonary embolism (C), and stroke (D) are not directly associated with alcohol abuse. Kidney disease is more commonly linked to conditions like diabetes and hypertension, pulmonary embolism is often related to blood clotting disorders, and stroke can be caused by factors such as hypertension and atherosclerosis.

Correct Answer: B

Rationale: The correct answer is B because culture is indeed rooted in specific social elements such as language, customs, traditions, beliefs, and values. These elements are passed down through generations within a particular society or group. Choice A is incorrect because culture is not genetically determined, but rather learned and acquired through socialization. Choice C is incorrect as culture plays a crucial role in shaping identities, behaviors, and interactions within a society. Choice D is incorrect as culture is not biologically determined, but rather socially constructed.

Correct Answer: C

Rationale: The correct answer is C: "Are you feeling so hopeless that you feel like hurting yourself now?" This response directly addresses the patient's suicidal ideation and assesses the immediate risk of harm. It shows the nurse's concern for the patient's safety and allows for further evaluation and intervention if necessary. Option A is incorrect because asking about owning a lethal weapon does not directly address the patient's current mental state and immediate risk of harm. Option B is incorrect as it focuses on external factors rather than the patient's internal feelings of hopelessness and suicidal thoughts. Option D is incorrect as it minimizes the seriousness of the patient's symptoms and may lead to overlooking the urgency of the situation.

Correct Answer: C

Rationale: The next appropriate action is to evaluate the individual's condition and compare actual outcomes with expected outcomes (Choice C). This step is crucial in determining the effectiveness of the implemented interventions in addressing the nursing diagnosis of acute pain. By evaluating the individual's condition, the nurse can assess whether the interventions have been successful in alleviating the pain. Comparing actual outcomes with expected outcomes helps in identifying any discrepancies and adjusting the plan of care accordingly to ensure optimal patient outcomes. Establishing priorities (Choice A) is important but would come before implementing interventions. Identifying expected outcomes (Choice B) is necessary before implementing interventions but does not directly address the need for evaluation. Interpreting data and making inferences (Choice D) is part of the assessment phase and not the next appropriate action after implementing interventions.

Correct Answer: D

Rationale: The correct answer is D: Worsening heart failure. Shortness of breath, fatigue, and leg swelling are common symptoms of heart failure. Monitoring for signs of worsening heart failure, such as increased dyspnea, weight gain, and decreased exercise tolerance, is crucial. Pulmonary embolism (A) presents with sudden chest pain and shortness of breath, not typically associated with chronic heart failure. Renal failure (B) may present with decreased urine output and electrolyte imbalances. Liver failure (C) may present with jaundice and changes in mental status. However, given the symptoms presented by the patient, monitoring for worsening heart failure is the most appropriate choice.

Correct Answer: B

Rationale: The correct answer is B: I will rotate injection sites to avoid tissue damage. This statement indicates proper understanding because rotating injection sites helps prevent tissue damage and ensures consistent absorption. Injecting into the same spot every time can lead to lipohypertrophy. Injecting insulin only when blood glucose is elevated is incorrect as insulin is needed regularly. Injecting into the arm for faster absorption is also incorrect, as it can lead to unpredictable absorption rates. Rotation of sites is crucial for optimal insulin absorption and to prevent complications.

Correct Answer: C

Rationale: The correct answer is C because observing the patient and inferring health or dysfunction allows the nurse to assess mental health holistically. This method considers various factors such as behavior, emotions, communication, and overall functioning. It provides a comprehensive view of the patient's mental well-being. A: Examining the patient's electroencephalogram is more related to brain activity rather than mental health assessment. B: Observing the patient as he or she performs an IQ test is limited to cognitive abilities and does not capture the full spectrum of mental health. D: Examining the patient's response to a specific set of questions may not provide a complete picture of mental health as it focuses on specific aspects rather than overall assessment.

Correct Answer: A

Rationale: The correct answer is A because when a patient is experiencing significant shortness of breath, the nurse should initially focus on assessing the areas directly related to the presenting problem to address the immediate issue. This approach allows for prompt intervention and treatment of the patient's acute condition. Once the patient's respiratory distress is managed, the nurse can then proceed with a complete assessment to identify any underlying or additional health issues. This stepwise approach ensures that the patient's urgent needs are met first before conducting a comprehensive assessment. Choices B, C, and D are incorrect because: B: Performing a mini-database by only examining body areas directly related to the problem may not provide a comprehensive understanding of the patient's condition and could overlook other potential health issues. C: Dismissing significant shortness of breath as a normal finding and proceeding with an abdominal assessment is inappropriate and could delay necessary interventions for the respiratory distress. D: Examining the entire body to determine if the problem is linked to something else is inefficient and