Nokea
A nurse is caring for a patient who has a history of myocardial infarction. The nurse should prioritize which of the following assessments?
- A. Blood pressure and heart rate.
- B. Temperature and respiratory rate.
- C. Bowel sounds and abdominal girth.
- D. Urine output and skin integrity.
Correct Answer: A
Rationale: The correct answer is A: Blood pressure and heart rate. This is crucial in assessing the cardiac function of a patient with a history of myocardial infarction. Monitoring blood pressure and heart rate helps in evaluating cardiovascular status and detecting any potential complications. Abnormal values in these parameters can indicate inadequate perfusion to the heart or other organs, which can be life-threatening.
Other choices are incorrect because:
B: Temperature and respiratory rate are important assessments but not the priority for a patient with a history of myocardial infarction.
C: Bowel sounds and abdominal girth are more relevant for gastrointestinal issues and not a priority in this scenario.
D: Urine output and skin integrity are important assessments for overall health but do not directly relate to the cardiovascular status in a patient with a history of myocardial infarction.
You may also like to solve these questions
A nurse is teaching a patient with asthma about managing triggers. Which of the following statements by the patient indicates the need for further education?
- A. I should avoid exposure to allergens and pollutants.
- B. I should avoid exercising outdoors in cold air.
- C. I should smoke to relieve stress and manage symptoms.
- D. I should use my inhaler before exercise if recommended by my doctor.
Correct Answer: C
Rationale: The correct answer is C: "I should smoke to relieve stress and manage symptoms." This statement indicates a need for further education because smoking can worsen asthma symptoms. Here's the rationale:
1. Smoking is a common trigger for asthma exacerbations due to irritants in tobacco smoke.
2. Smoking can lead to airway inflammation and constriction, making asthma symptoms more severe.
3. Asthma management involves avoiding smoking and secondhand smoke exposure.
4. Choices A, B, and D are correct as they align with asthma management guidelines to avoid triggers and use inhalers as prescribed.
Which of the following statements accurately reflects the concept of ethnicity?
- A. Ethnicity is dynamic and ever changing because of political forces.
- B. Ethnicity refers to a group that shares heritage, culture, language, or religion.
- C. Ethnicity refers to the belief in a higher power or being.
- D. Ethnicity is a learned behaviour that includes language and socialization.
Correct Answer: B
Rationale: The correct answer is B because ethnicity is defined by shared heritage, culture, language, or religion. This definition encompasses the key components that make up an individual's ethnic identity. Choice A is incorrect because while political forces may influence ethnicity, it does not define the concept itself. Choice C is incorrect as ethnicity is not necessarily related to belief in a higher power. Choice D is incorrect as ethnicity is not solely a learned behavior but also includes innate aspects like heritage.
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should encourage the patient to perform which of the following exercises to prevent complications?
- A. Quadriceps setting exercises.
- B. Leg lifts with weights.
- C. Isometric muscle contractions.
- D. Active range-of-motion exercises.
Correct Answer: A
Rationale: The correct answer is A: Quadriceps setting exercises. These exercises help prevent complications by strengthening the quadriceps muscles, which are crucial for knee stability and joint support post-surgery. They also aid in preventing muscle atrophy and promoting blood circulation. Leg lifts with weights (B) may strain the knee joint, leading to complications. Isometric muscle contractions (C) involve static muscle contractions and do not provide the necessary range of motion needed post-knee surgery. Active range-of-motion exercises (D) may be beneficial but should be performed after quadriceps setting exercises to avoid unnecessary strain on the knee joint.
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
- A. Ask the patient to take deep breaths to relax the abdominal musculature.
- B. Consider this a normal finding, and proceed with the abdominal assessment.
- C. Use less force to percuss over the abdomen.
- D. Use more force to percuss over the abdomen.
Correct Answer: C
Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.
A 60-year-old woman is undergoing a mammogram. The nurse explains that the procedure is done to:
- A. Detect any abnormal growths or tumors in the breast tissue.
- B. Identify changes in hormone levels.
- C. Evaluate lung function related to breast cancer.
- D. Assess for signs of osteoporosis.
Correct Answer: A
Rationale: The correct answer is A because mammograms are specifically designed to detect abnormal growths or tumors in the breast tissue, particularly in the early stages of breast cancer. This is crucial for early detection and effective treatment.
Choice B is incorrect because mammograms are not used to identify changes in hormone levels. Choice C is incorrect because mammograms do not evaluate lung function related to breast cancer. Choice D is incorrect because mammograms do not assess for signs of osteoporosis; a bone density scan is typically used for that purpose.