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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.
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A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for signs of which of the following complications?
- A. Hypoglycemia.
- B. Respiratory failure.
- C. Hyperkalemia.
- D. Anemia.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD are at risk for respiratory failure due to impaired gas exchange and respiratory muscle weakness. This can lead to hypoxia and hypercapnia. Monitoring for signs such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial.
Hypoglycemia (A) is not a common complication of COPD. Hyperkalemia (C) is less likely to occur in COPD unless the patient is on medications that can cause elevated potassium levels. Anemia (D) may be present in COPD due to chronic inflammation, but it is not a direct complication that requires monitoring for signs of respiratory failure.
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.
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.
The interview portion of data collection obtains:
- A. Physical data.
- B. Historical data.
- C. Objective data.
- D. Subjective data.
Correct Answer: D
Rationale: The correct answer is D: Subjective data. During the interview portion of data collection, subjective data is obtained as it involves personal opinions, feelings, and experiences shared by the interviewee. This data is based on individual perspectives and cannot be measured objectively. Physical data (A) refers to tangible measurements, historical data (B) relates to past events or records, and objective data (C) is based on observable and measurable facts. In contrast, subjective data (D) captures the interviewee's viewpoints and interpretations, making it the most appropriate choice for the given scenario.
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should monitor for which of the following complications?
- A. Pneumonia.
- B. Deep vein thrombosis (DVT).
- C. Wound infection.
- D. Hypoglycemia.
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Post-operative hip replacement patients are at high risk for DVT due to immobility and surgical trauma. The nurse should monitor for signs such as swelling, redness, and pain in the affected leg. DVT can lead to serious complications like pulmonary embolism if not detected early. Choices A, C, and D are incorrect because while pneumonia, wound infection, and hypoglycemia are also potential post-operative complications, they are not as directly associated with hip replacement surgery as DVT.