Nokea
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.
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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.
Which of the following best describes a proficient nurse?
- A. A nurse who has little experience with a specified population and uses rules to guide performance
- B. A nurse who has an intuitive grasp of a clinical situation and quickly identifies the accurate solution
- C. A nurse who sees actions in the context of daily plans for patients
- D. A nurse who sees a patient's situation as a whole, with long-term goals for the patient, rather than as a list of tasks to be performed
Correct Answer: D
Rationale: The correct answer is D because a proficient nurse should have a holistic view of the patient's situation, focusing on long-term goals rather than just completing tasks. This approach ensures comprehensive care and better outcomes. Choice A is incorrect as it implies reliance on rules over experience. Choice B is incorrect because intuition alone may not always lead to the best solution. Choice C is incorrect as it emphasizes daily plans rather than long-term goals.
A nurse is teaching a patient with hypertension about lifestyle modifications. Which of the following dietary changes should the nurse emphasize?
- A. Increase intake of foods high in sodium.
- B. Decrease intake of saturated fats.
- C. Increase intake of processed foods.
- D. Decrease intake of fiber.
Correct Answer: B
Rationale: The correct answer is B: Decrease intake of saturated fats. Saturated fats can raise cholesterol levels, leading to increased risk of heart disease and hypertension. Decreasing intake of saturated fats can help lower blood pressure.
Incorrect choices:
A: Increasing intake of foods high in sodium can worsen hypertension by increasing blood pressure.
C: Increasing intake of processed foods often leads to higher sodium and saturated fat intake, worsening hypertension.
D: Decreasing intake of fiber is not ideal as fiber helps in maintaining a healthy weight and managing blood pressure.
The nurse is assessing mental health in children. Which of the following statements is true?
- A. All aspects of mental health in children are interrelated.
- B. Children are highly labile and unstable until the age of 2 years.
- C. Until the age of 7 years, children's mental health is largely a function of their parents' mental health.
- D. Children's mental health is impossible to assess until they develop the ability to concentrate.
Correct Answer: A
Rationale: The correct answer is A because all aspects of mental health in children are indeed interrelated. Mental health encompasses various components such as emotional, social, and psychological well-being, which are interconnected and influence each other. Understanding and assessing mental health in children require considering the holistic picture.
Choice B is incorrect because children are not inherently labile and unstable until the age of 2 years. Choice C is incorrect as children's mental health is influenced by various factors beyond just their parents' mental health. Choice D is incorrect because mental health assessment in children can be done using age-appropriate methods even before they develop the ability to concentrate.
Which of the following statements best describes the Montreal Cognitive Assessment (MoCA) examination?
- A. Scores below 30 indicate cognitive impairment.
- B. It is a good tool to evaluate mood and thought processes.
- C. It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
- D. It is useful for an initial evaluation of mental health. Additional tools are needed to evaluate changes in cognition over time.
Correct Answer: C
Rationale: The correct answer is C because the Montreal Cognitive Assessment (MoCA) is specifically designed to detect delirium and dementia and differentiate these conditions from psychiatric mental illness. It assesses various cognitive domains such as memory, attention, language, and visuospatial abilities. Scores below the normal range on the MoCA can indicate cognitive impairment related to delirium or dementia.
Choice A is incorrect because a score below 30 on the MoCA does not necessarily indicate cognitive impairment; it depends on the individual's baseline and education level.
Choice B is incorrect because the MoCA primarily focuses on cognitive function rather than mood and thought processes.
Choice D is incorrect because while the MoCA can be used for initial evaluation of cognitive function, it is not sufficient for evaluating changes over time. Additional tools and assessments are needed for longitudinal monitoring of cognitive changes.