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A nurse is caring for a patient who has just had a stroke. Which of the following should the nurse monitor for?
- A. Severe headache
- B. Dehydration
- C. Respiratory depression
- D. Sudden loss of vision
Correct Answer: C
Rationale: The correct answer is C: Respiratory depression. After a stroke, the patient may experience impaired breathing due to neurological damage affecting the respiratory center in the brain. Monitoring for signs of respiratory depression, such as shallow breathing or decreased oxygen saturation, is crucial to prevent respiratory failure. Severe headache (A) may be a symptom of stroke but is not the highest priority for monitoring. Dehydration (B) is important to prevent but not typically a direct consequence of stroke. Sudden loss of vision (D) may occur with certain types of strokes but is not as critical to monitor as respiratory depression.
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In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the:
- A. last glaucoma examination.
- B. frequency of breast self-examination.
- C. date of her last electrocardiogram.
- D. limitations related to her involvement in sports activities.
Correct Answer: D
Rationale: The correct answer is D because obtaining information on the limitations related to the girl's involvement in sports activities is crucial for assessing her overall physical health and well-being. This information helps in understanding any potential risks or issues that may arise from her participation in sports. Choices A, B, and C are incorrect as they are not relevant to a review of systems for a healthy 7-year-old girl. Glaucoma examination, breast self-examination frequency, and electrocardiogram date are not typically part of a routine review of systems for a child of her age and health status.
A nurse is caring for a patient who has undergone a total knee replacement. Which of the following interventions is most important to prevent post-operative complications?
- A. Encouraging early ambulation.
- B. Providing pain medication as needed.
- C. Monitoring for signs of infection.
- D. Administering antibiotics before surgery.
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. Early ambulation helps prevent complications such as deep vein thrombosis and pulmonary embolism by improving circulation and preventing blood clots. It also promotes joint mobility and muscle strength. Providing pain medication (B) is important but not as crucial as preventing complications. Monitoring for signs of infection (C) is essential but not the most important intervention. Administering antibiotics before surgery (D) does not directly prevent post-operative complications related to knee replacement.
A nurse is caring for a patient with diabetes who is experiencing hypoglycemia. The nurse should prioritize which of the following interventions?
- A. Administering insulin.
- B. Providing a source of fast-acting carbohydrate.
- C. Administering an oral hypoglycemic agent.
- D. Monitoring the patient's blood pressure.
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In hypoglycemia, the priority is to quickly raise the patient's blood sugar levels to prevent potential complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (A) would further lower blood sugar levels, worsening the situation. Administering an oral hypoglycemic agent (C) is not appropriate in an acute hypoglycemic episode. Monitoring blood pressure (D) is important but not the priority in this situation.
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions to prevent complications?
- A. Encouraging early ambulation and use of compression stockings.
- B. Administering pain medication regularly.
- C. Monitoring for signs of infection.
- D. Providing nutritional support and hydration.
Correct Answer: A
Rationale: The correct answer is A. Encouraging early ambulation and use of compression stockings is crucial post-abdominal surgery to prevent complications like deep vein thrombosis and pneumonia. Ambulation helps prevent blood clots and promotes lung expansion. Compression stockings aid in preventing blood pooling in the legs. Administering pain medication regularly (B) is important but not the priority. Monitoring for infection (C) is essential but not the priority immediately post-op. Providing nutritional support and hydration (D) is important but not as critical as preventing immediate complications.
A nurse is caring for a patient with a history of stroke. The nurse should monitor the patient for signs of:
- A. Pulmonary embolism.
- B. Atrial fibrillation.
- C. Chronic kidney disease.
- D. Sepsis.
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. Patients with a history of stroke are at an increased risk of atrial fibrillation, a common cause of ischemic stroke. Monitoring for signs of atrial fibrillation such as irregular heartbeat, palpitations, dizziness, and chest discomfort is crucial for early detection and prevention of recurrent strokes. Pulmonary embolism (A), chronic kidney disease (C), and sepsis (D) are not directly associated with a history of stroke and would not be the primary focus of monitoring in this case.