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A nurse is assessing a patient's hydration status. Which of the following findings would suggest dehydration?
- A. Increased urine output
- B. Decreased heart rate
- C. Dry mucous membranes
- D. Increased blood pressure
Correct Answer: C
Rationale: The correct answer is C: Dry mucous membranes. Dry mucous membranes are a common sign of dehydration as the body lacks adequate fluid. When a person is dehydrated, there is a decrease in saliva production, leading to dryness in the mouth and throat. This can be easily observed during a physical examination by looking at the patient's lips, tongue, and inside of the mouth. On the other hand, increased urine output (choice A) is a sign of adequate hydration, decreased heart rate (choice B) can be a normal response to dehydration but is not a consistent indicator, and increased blood pressure (choice D) is not typically associated with dehydration. Therefore, dry mucous membranes are the most reliable finding to suggest dehydration in a patient.
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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.
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.
A nurse is teaching a patient with a new diagnosis of diabetes about managing blood glucose levels. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood glucose levels regularly.
- B. I should follow a healthy diet to manage my condition.
- C. I can stop taking my insulin when my blood sugar is normal.
- D. I will exercise regularly to improve my health.
Correct Answer: C
Rationale: The correct answer is C: "I can stop taking my insulin when my blood sugar is normal." This statement indicates a misunderstanding of diabetes management. Here's the rationale:
1. Insulin is a crucial medication for managing diabetes, and stopping it abruptly can lead to serious complications.
2. Blood sugar levels can fluctuate, so stopping insulin when levels are normal is not safe or effective.
3. Proper education should emphasize the importance of consistent insulin use as prescribed by healthcare providers.
4. Choices A, B, and D demonstrate good understanding of diabetes management by focusing on monitoring blood glucose levels, following a healthy diet, and exercising regularly.
A nurse is caring for a patient with hypertension. The nurse should educate the patient to monitor for which of the following complications?
- A. Severe headaches and blurred vision.
- B. Weight loss and fatigue.
- C. Increased appetite and tremors.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A: Severe headaches and blurred vision. These symptoms can indicate a hypertensive crisis, a severe complication of hypertension. Headaches and blurred vision are signs of potentially dangerous high blood pressure levels. Weight loss and fatigue (B), increased appetite and tremors (C), and nausea and vomiting (D) are not typical complications of hypertension and do not directly relate to the cardiovascular effects of high blood pressure. Monitoring for severe headaches and blurred vision is crucial for early detection and management of hypertensive crises.
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should prioritize which of the following interventions to prevent complications?
- A. Administering pain medication as needed.
- B. Encouraging early ambulation and use of compression stockings.
- C. Providing nutritional support and supplements.
- D. Monitoring for signs of infection.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation and use of compression stockings. This intervention is crucial post-hip replacement to prevent complications such as blood clots and muscle weakness. Early ambulation helps prevent blood clots by promoting circulation, and compression stockings further aid in preventing deep vein thrombosis. Pain medication (A) is important but not the priority in preventing complications. Providing nutritional support (C) is also important but does not directly prevent post-operative complications. Monitoring for signs of infection (D) is essential but not as immediate as promoting early ambulation to prevent complications.