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A nurse is assessing a patient with a history of hypertension. Which of the following findings would be most concerning?
- A. A blood pressure reading of 160/100 mm Hg.
- B. A blood pressure reading of 130/85 mm Hg.
- C. A blood pressure reading of 140/90 mm Hg.
- D. A blood pressure reading of 120/80 mm Hg.
Correct Answer: A
Rationale: The correct answer is A. A blood pressure reading of 160/100 mm Hg is most concerning because it falls within the hypertensive crisis range, indicating severely elevated blood pressure that requires immediate medical attention to prevent complications like stroke or heart attack. Choices B, C, and D are within the prehypertension or mild hypertension ranges and are not as immediately concerning.
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Which of the following is an example of a secondary prevention activity?
- A. Routine immunizations
- B. Health screenings such as mammograms
- C. Smoking cessation programs
- D. Health education on healthy eating
Correct Answer: B
Rationale: The correct answer is B, Health screenings such as mammograms, because secondary prevention focuses on early detection and treatment of diseases to prevent progression. Health screenings help identify conditions at early stages, allowing for timely intervention. Routine immunizations (A) are considered primary prevention as they prevent diseases from occurring. Smoking cessation programs (C) and health education on healthy eating (D) are examples of primary prevention, as they aim to prevent the development of diseases by promoting healthy behaviors.
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?' The nurse tells her:
- A. They are signs of decreased hematocrit related to anemia.
- B. They are due to destruction of melanin in your skin due to exposure to the sun.
- C. They are clusters of melanocytes that appear after prolonged sun exposure.
- D. They are areas of hyperpigmentation related to decreased perfusion and vasoconstriction.
Correct Answer: C
Rationale: The correct answer is C because the small, flat, brown macules described are consistent with lentigines (commonly known as age or liver spots), which are clusters of melanocytes that appear after prolonged sun exposure. This explanation directly addresses the patient's question about the cause of the spots and is supported by the clinical presentation.
Choice A is incorrect because decreased hematocrit related to anemia would not cause these specific skin changes. Choice B is incorrect as destruction of melanin due to sun exposure would result in lighter spots, not dark brown macules. Choice D is incorrect because hyperpigmentation related to decreased perfusion and vasoconstriction would present differently and not primarily on sun-exposed areas like the arms and hands.
The nurse has just started an assessment of the newborn child of a woman of Vietnamese origin. Considering the mother's cultural background, which of the following statements about this examination is true? The mother:
- A. Will be offended if the infant's fontanelles are examined.
- B. Will be offended if the infant's diaper area is touched during the examination.
- C. Would prefer to have the results of the examination communicated directly to her husband.
- D. Would prefer to receive written report about her child's growth and development, rather than a verbal one.
Correct Answer: A
Rationale: The correct answer is A because in Vietnamese culture, touching or examining the fontanelles (soft spots on a baby's head) is considered disrespectful and potentially harmful. This is due to the belief that the fontanelles are fragile and touching them can impact the baby's health. It is crucial for the nurse to respect and be sensitive to the cultural beliefs and practices of the mother to establish trust and provide culturally competent care.
Choice B is incorrect because there is no specific cultural taboo in Vietnamese culture about touching the infant's diaper area during examination. Choice C is incorrect as assuming that the husband should be the primary communicator of medical information goes against the principle of patient autonomy. Choice D is incorrect as there is no indication that Vietnamese mothers prefer written reports over verbal communication regarding their child's growth and development.
A 45-year-old woman is at the clinic for a mental health assessment. When giving her the Four Unrelated Words Test, the nurse would be concerned if the patient:
- A. Could not give four unrelated words within 5 minutes.
- B. Could not give four unrelated words within 30 seconds.
- C. Could not recall four unrelated words after a 30-minute delay.
- D. Could not recall four unrelated words after a 60-minute delay.
Correct Answer: C
Rationale: The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall.
A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task.
B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue.
D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.
While working in the surgical unit, the nurse notices that a patient speaks a language that she cannot understanThe nurse is aware that the hospital has a number of postoperative instructions, translated videos, and brochures in this patient's language, in addition to having a translator on staff. These are all examples of:
- A. language services that are available to all admitted patients.
- B. the standards for cultural and linguistically appropriate services.
- C. ways of addressing diverse communication needs.
- D. efforts to improve patient satisfaction and care
Correct Answer: B
Rationale: The correct answer is B: the standards for cultural and linguistically appropriate services. The rationale is as follows:
1. Cultural and linguistically appropriate services ensure that patients receive care that is respectful of and responsive to their cultural and linguistic needs.
2. Having translated materials and a translator on staff aligns with these standards by providing access to healthcare information in the patient's language.
3. By offering postoperative instructions and resources in the patient's language, the hospital is promoting effective communication and understanding.
4. These services aim to reduce language barriers, improve patient outcomes, and enhance the overall quality of care.