Nokea
A nurse is caring for a patient who is post-operative following a cesarean section. The nurse should prioritize which of the following interventions?
- A. Administering pain medication as prescribed.
- B. Encouraging the patient to breastfeed immediately.
- C. Monitoring for signs of hemorrhage.
- D. Encouraging ambulation to prevent deep vein thrombosis.
Correct Answer: C
Rationale: The correct answer is C: Monitoring for signs of hemorrhage. This is the priority intervention because post-cesarean section hemorrhage is a life-threatening complication that requires immediate attention. The nurse should monitor the patient's vital signs, uterine firmness, and amount of vaginal bleeding to detect any signs of hemorrhage and take prompt action if necessary.
Option A is incorrect because pain management is important but not the priority in this situation. Option B is also incorrect as breastfeeding can be encouraged after the patient's condition is stable. Option D is not the priority as preventing deep vein thrombosis is important but not as urgent as monitoring for hemorrhage.
You may also like to solve these questions
A nurse is assessing a 45-year-old male patient with a history of smoking. The nurse would be most concerned if the patient reports:
- A. Shortness of breath with minimal exertion.
- B. Occasional cough with mucus production.
- C. Slight wheezing after physical activity.
- D. Experiencing no symptoms related to smoking.
Correct Answer: A
Rationale: The correct answer is A because shortness of breath with minimal exertion indicates possible respiratory distress, which can be a sign of significant lung damage from smoking. This symptom suggests a decreased ability to exchange oxygen and carbon dioxide efficiently, potentially leading to serious health complications.
Choice B is incorrect because an occasional cough with mucus production is common in smokers and may not be as alarming as shortness of breath.
Choice C is incorrect as slight wheezing after physical activity could be due to exercise-induced asthma rather than solely smoking-related issues.
Choice D is incorrect because even though the patient may not be experiencing symptoms related to smoking currently, it does not rule out potential underlying lung damage or future health risks associated with smoking.
A nurse is caring for a patient who has a history of myocardial infarction. The nurse should prioritize which of the following assessments?
- A. Blood pressure and heart rate.
- B. Temperature and respiratory rate.
- C. Bowel sounds and abdominal girth.
- D. Urine output and skin integrity.
Correct Answer: A
Rationale: The correct answer is A: Blood pressure and heart rate. This is crucial in assessing the cardiac function of a patient with a history of myocardial infarction. Monitoring blood pressure and heart rate helps in evaluating cardiovascular status and detecting any potential complications. Abnormal values in these parameters can indicate inadequate perfusion to the heart or other organs, which can be life-threatening.
Other choices are incorrect because:
B: Temperature and respiratory rate are important assessments but not the priority for a patient with a history of myocardial infarction.
C: Bowel sounds and abdominal girth are more relevant for gastrointestinal issues and not a priority in this scenario.
D: Urine output and skin integrity are important assessments for overall health but do not directly relate to the cardiovascular status in a patient with a history of myocardial infarction.
A nurse is caring for a patient who is post-operative following an appendectomy. The nurse should prioritize which of the following in the immediate post-operative period?
- A. Administering pain medication.
- B. Encouraging early ambulation.
- C. Monitoring vital signs and fluid status.
- D. Providing wound care and dressing changes.
Correct Answer: C
Rationale: The correct answer is C, monitoring vital signs and fluid status, because it is crucial for assessing the patient's immediate post-operative condition and detecting any signs of complications like hemorrhage or shock. This step ensures early intervention if any issues arise, promoting patient safety and recovery. Administering pain medication (A) is important but not the top priority. Encouraging early ambulation (B) and providing wound care (D) are also essential but come after ensuring the patient's vital signs and fluid status are stable.
Which of the following statements about mental health assessment is true?
- A. The mental health assessment diagnoses specific psychiatric disorders.
- B. Mental disorders occur in response to everyday life stressors.
- C. Mental status is inferred through assessment of an individual's behaviours.
- D. Mental health can be assessed directly, just like the characteristics of any other body system (e.g., cardiac and breath sounds).
Correct Answer: C
Rationale: The correct answer is C because mental status is indeed inferred through assessment of an individual's behaviors. Mental health assessment involves observing and evaluating a person's thoughts, emotions, behaviors, and overall mental functioning to determine their mental status. This includes assessing speech, mood, cognition, and perception. Choices A, B, and D are incorrect because:
A: Mental health assessment does not solely focus on diagnosing specific psychiatric disorders; it is a broader evaluation of an individual's mental well-being.
B: Mental disorders can result from a variety of factors beyond everyday life stressors, such as genetic predisposition or traumatic experiences.
D: Mental health assessment is more complex than assessing physical characteristics and involves subjective interpretation of behaviors rather than direct observation like physical assessments.
A nurse is caring for a patient with a history of hypertension. The nurse should prioritize which of the following interventions?
- A. Administering antihypertensive medication as prescribed.
- B. Encouraging weight loss.
- C. Monitoring blood pressure regularly.
- D. Promoting a low-sodium diet.
Correct Answer: A
Rationale: The correct answer is A: Administering antihypertensive medication as prescribed. This is the priority intervention because it directly addresses the patient's hypertension, which is a critical condition that needs immediate management to prevent complications. Encouraging weight loss (B), monitoring blood pressure (C), and promoting a low-sodium diet (D) are all important aspects of managing hypertension. However, administering antihypertensive medication takes precedence as it directly targets lowering blood pressure and reducing the risk of cardiovascular events. Weight loss, monitoring, and dietary changes are important for long-term management but may not provide immediate control of hypertension compared to medication.