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A 22-year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?
- A. The patient is excited about being around family again.
- B. The patient's suicide plan has probably progressed.
- C. The patient's plans for the future have been clarified.
- D. The patient's mood is improving.
Correct Answer: B
Rationale: In this scenario, it is concerning that a patient under suicide watch is happy about being discharged as it may indicate that the patient's suicide plan has advanced. This change in behavior should be taken seriously as it can signal an increased risk of self-harm. Choices A, C, and D are less likely as the patient's happiness about discharge in this context is more indicative of a worsening situation rather than positive outcomes like being around family, clarifying future plans, or improving mood.
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A person who had a left CVA and right lower extremity hemiparesis is being instructed by a nurse to use a quad cane. Which of the following is the most appropriate gait sequence?
- A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
- C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
Correct Answer: A
Rationale: The correct gait sequence for a person with left CVA and right lower extremity hemiparesis using a quad cane is to place the cane in the patient's strong upper extremity, which is the left upper extremity in this case. The correct sequence should be right lower extremity followed by left upper extremity, as this pattern mimics a normal gait pattern. Therefore, Choice A is the correct answer. Choices B, C, and D are incorrect because they do not follow the proper gait sequence for this specific patient's condition. The cane should be placed in the strong upper extremity, and the affected lower extremity should move first to provide stability and support, which is essential in this situation.
Which instruction should be given in a health education class regarding testicular cancer?
- A. All males should perform a testicular exam after a warm bath or shower.
- B. Testicular exams should be performed on a daily basis.
- C. Reddening or darkening of the scrotum is a normal finding.
- D. Testicular exams should be performed after a warm bath or shower.
Correct Answer: D
Rationale: The correct instruction for testicular cancer education is that testicular exams should be performed after a warm bath or shower as it relaxes the scrotum and makes the exam easier. Testicular exams should be done monthly by all men starting around age 15, not after the age of 30 (Choice A) or on a daily basis (Choice B), which is unnecessary and may lead to unnecessary anxiety. Reddening or darkening of the scrotum is not a normal finding (Choice C) and should be reported to a healthcare provider for further evaluation.
A patient has suffered a left CVA and developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema, and the skin is intact. The nurse should score the patient as having which of the following?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct Answer: A
Rationale: Erythema with the skin intact is characteristic of a Stage I pressure ulcer. At this stage, the skin is not broken, but there is localized redness that does not blanch when pressed. Stage II pressure ulcers involve partial-thickness skin loss, Stage III pressure ulcers have full-thickness skin loss, and Stage IV pressure ulcers extend to deeper tissues, including muscle and bone. In this case, the non-blanchable erythema with intact skin aligns with the characteristics of a Stage I pressure ulcer.
Which of the following is not typically considered one of the main mechanisms of Type II Diabetes treatment?
- A. Medications
- B. Nutrition
- C. Increased activity
- D. Continuous Insulin
Correct Answer: D
Rationale: Continuous Insulin is not typically considered one of the main mechanisms for treating Type II Diabetes. While medications, nutrition, and increased activity play crucial roles in managing Type II Diabetes, continuous insulin therapy is more common in Type I Diabetes or in specific cases of Type II Diabetes where other treatments are ineffective. Therefore, the correct answer is Continuous Insulin. Choices A, B, and C are mainstays in the treatment of Type II Diabetes, making them incorrect answers.
At what age will vision be 20/20 in children?
- A. 4 years old
- B. 5 years old
- C. 6 years old
- D. 7 years old
Correct Answer: C
Rationale: The correct answer is 6 years old. At this age, children typically have the potential for 20/20 vision. This is considered the standard age for achieving optimal vision clarity. Choices A, B, and D are incorrect as they are not typically associated with the age at which children achieve 20/20 vision.