Nokea
A nurse is caring for a patient who is post-operative following hip replacement surgery. Which of the following should be included in the nursing care plan to prevent complications?
- A. Encouraging the patient to avoid physical activity for several weeks.
- B. Administering pain medication only when requested by the patient.
- C. Monitoring the patient for signs of infection and deep vein thrombosis.
- D. Providing education on safe lifting techniques.
Correct Answer: C
Rationale: The correct answer is C because monitoring the patient for signs of infection and deep vein thrombosis is crucial in preventing complications post-hip replacement surgery. Infections can lead to serious complications, while deep vein thrombosis can result in blood clots that can be life-threatening. By closely monitoring for these signs, the nurse can intervene early and prevent further complications.
Choice A is incorrect because complete avoidance of physical activity can lead to other complications such as muscle atrophy and delayed recovery. Choice B is incorrect because pain management should be proactive to prevent unnecessary suffering. Choice D, while important, is not directly related to preventing complications such as infection and deep vein thrombosis.
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The nurse notices that the patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:
- A. Bulla.
- B. Wheal.
- C. Nodule.
- D. Papule.
Correct Answer: D
Rationale: The correct answer is D: Papule. A papule is a solid, elevated lesion that is less than 1 cm in diameter. It is circumscribed, meaning it has well-defined borders. Papules are often associated with skin conditions like acne or insect bites.
A: Bulla is a large fluid-filled blister, not a solid lesion.
B: Wheal is a raised, red area of skin that is typically transient and caused by an allergic reaction.
C: Nodule is a solid, elevated lesion that is greater than 1 cm in diameter, not less than 1 cm.
A nurse is teaching a patient about managing high cholesterol. Which of the following dietary changes would be most beneficial for lowering cholesterol?
- A. Increasing intake of saturated fats.
- B. Decreasing intake of dietary fiber.
- C. Decreasing intake of trans fats.
- D. Increasing intake of processed sugars.
Correct Answer: C
Rationale: The correct answer is C: Decreasing intake of trans fats. Trans fats are known to increase LDL cholesterol levels, which are considered "bad" cholesterol. By reducing trans fats in the diet, the patient can lower their cholesterol levels. Saturated fats (choice A) can also increase LDL cholesterol, so increasing intake is not beneficial. Dietary fiber (choice B) helps lower cholesterol by binding to cholesterol in the digestive system, so decreasing intake would not be beneficial. Processed sugars (choice D) do not directly impact cholesterol levels, so increasing intake would not help lower cholesterol. Overall, choosing option C is the most effective dietary change for managing high cholesterol.
A 90-year-old patient tells the nurse that he is unable to remember the names of the medications he is taking or what they are for. An appropriate response would be:
- A. "Can you tell me what they look like?"
- B. "Don't worry about it. You are only taking two."
- C. "How long have you been taking each of these pills?"
- D. "Would you ask your family to bring in your medications?"
Correct Answer: D
Rationale: The correct answer is D because asking the patient's family to bring in the medications will ensure accurate identification and understanding of the medications. This step is crucial in ensuring the patient's safety and well-being. Choice A is incorrect as appearance alone may not provide accurate information. Choice B is dismissive and does not address the issue. Choice C focuses on duration rather than addressing the immediate concern of medication identification.
A nurse is assessing a patient who is post-operative following a hip replacement. Which of the following is the most important nursing priority after surgery?
- A. Managing pain.
- B. Monitoring for infection.
- C. Preventing deep vein thrombosis (DVT).
- D. Ensuring proper positioning.
Correct Answer: C
Rationale: The correct answer is C: Preventing deep vein thrombosis (DVT). It is the most important nursing priority after hip replacement surgery because patients are at high risk for DVT due to immobility and altered blood flow. DVT can lead to serious complications like pulmonary embolism. Monitoring for infection (B) is important but preventing DVT takes precedence. Managing pain (A) is essential but not the top priority. Ensuring proper positioning (D) is important for preventing complications, but DVT prevention is more critical post-hip replacement surgery.
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but laughs loudly when looking at it. This behaviour is a display of:
- A. Confusion.
- B. Ambivalence.
- C. Depersonalization.
- D. Inappropriate affect.
Correct Answer: D
Rationale: The correct answer is D: Inappropriate affect. Inappropriate affect refers to emotions that are not congruent with the situation. In this case, the patient's laughing while describing a horrifying image indicates a disconnect between his emotions and the context. This behavior is commonly seen in schizophrenia, where there is a lack of appropriate emotional response.
A: Confusion does not accurately describe the patient's behavior, as he is able to describe the picture and his emotional response to it.
B: Ambivalence refers to conflicting emotions or attitudes, which is not evident in the patient's behavior.
C: Depersonalization involves feeling detached from oneself or reality, which is not evident in the patient's behavior.
In summary, the patient's inappropriate laughter in response to a horrifying image is indicative of inappropriate affect, a common feature of schizophrenia.