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A nurse is caring for a patient who has undergone a knee replacement. The nurse should encourage which of the following to promote recovery?
- A. Strict bed rest for the first 48 hours.
- B. Ambulation as soon as possible after surgery.
- C. Limiting physical activity for 2 weeks post-op.
- D. Prolonged use of the affected leg in a cast.
Correct Answer: B
Rationale: The correct answer is B: Ambulation as soon as possible after surgery. Ambulation helps prevent complications like blood clots and aids in circulation and muscle strength. Bed rest can lead to stiffness and decrease in range of motion. Limiting physical activity delays recovery. Prolonged use of a cast can hinder mobility and delay rehabilitation.
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A 45-year-old woman suffered a head injury in a car accident. A few months after recovering from her injuries, she is unable to differentiate between hot and cold and is unsure of how to dress for the weather. This is an example of:
- A. Mania.
- B. Agnosia.
- C. Dementia.
- D. Amnestic disorder.
Correct Answer: B
Rationale: The correct answer is B: Agnosia. Agnosia is the inability to recognize or interpret sensory information, such as temperature or clothing. In this case, the woman's inability to differentiate between hot and cold and dress appropriately for the weather indicates a sensory processing issue, characteristic of agnosia.
A: Mania is a mood disorder characterized by extreme excitement and impulsivity, not related to sensory perception issues.
C: Dementia is a broad term for cognitive decline, which typically includes memory loss and impaired decision-making, but not necessarily sensory perception deficits.
D: Amnestic disorder refers to memory impairment, not the inability to interpret sensory information.
A nurse is about to perform an assessment of a patient's lungs. Which of the following is the most appropriate action before auscultation?
- A. Ask the patient to take deep breaths
- B. Have the patient sit upright
- C. Examine for symmetry
- D. Ask the patient to lie flat and breathe normally
Correct Answer: D
Rationale: The correct answer is D: Ask the patient to lie flat and breathe normally. This position allows for optimal lung expansion, making it easier to hear breath sounds accurately. Asking the patient to lie flat also provides a consistent baseline for comparison across different patients.
A: Asking the patient to take deep breaths before auscultation may alter their normal breathing pattern and make it difficult to assess baseline lung sounds accurately.
B: Having the patient sit upright can be helpful for certain assessments, but lying flat is preferred for auscultating lung sounds.
C: Examining for symmetry is important but not directly related to the optimal position for auscultation.
A nurse is teaching a patient with asthma about proper inhaler use. Which of the following statements by the patient indicates the need for further education?
- A. I should hold my breath for 10 seconds after inhaling the medication.
- B. I should use my inhaler before exercise to prevent symptoms.
- C. I can use my inhaler every 30 minutes if I have trouble breathing.
- D. I should rinse my mouth after using my inhaler to prevent thrush.
Correct Answer: C
Rationale: The correct answer is C because using the inhaler every 30 minutes for trouble breathing is not recommended. Overuse can lead to medication side effects and potential worsening of symptoms.
A: Holding breath after inhaling helps medication reach lungs.
B: Using inhaler before exercise can prevent exercise-induced symptoms.
D: Rinsing mouth prevents thrush, a common side effect of inhaled corticosteroids.
A nurse is caring for a patient with a history of diabetes. The nurse should monitor for signs of which of the following complications?
- A. Hyperglycemia.
- B. Hypoglycemia.
- C. Dehydration.
- D. Hypotension.
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels. Monitoring for hyperglycemia is crucial to prevent complications like diabetic ketoacidosis. Hypoglycemia (B) is low blood sugar, dehydration (C) is not directly related to diabetes unless it causes hyperosmolar hyperglycemic state, and hypotension (D) is low blood pressure, which is not a common complication of diabetes. Regular monitoring for hyperglycemia helps in preventing diabetic complications.
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the:
- A. nursing diagnosis.
- B. medical diagnosis.
- C. admission diagnosis.
- D. collaborative diagnosis.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Nursing interventions are based on nursing diagnosis, which identifies patient's unique health needs.
2. Nursing diagnosis focuses on patient's response to health problems, not just medical conditions.
3. It guides nurses in planning individualized care to meet patient's specific needs.
4. Medical diagnosis (B) focuses on disease pathology, not holistic patient care.
5. Admission diagnosis (C) is a temporary identification of patient's primary reason for admission.
6. Collaborative diagnosis (D) involves joint identification of interprofessional health problems, not specific to nursing care.
Summary:
The correct answer is A because nursing interventions are tailored based on nursing diagnosis, which considers patient's responses to health issues. Medical diagnosis, admission diagnosis, and collaborative diagnosis do not provide the same level of individualized and holistic care planning as nursing diagnosis.