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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.
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A nurse is caring for a patient with hypertension. The nurse should educate the patient to avoid which of the following?
- A. Limiting caffeine intake.
- B. Consuming more fruits and vegetables.
- C. Increasing salt intake.
- D. Increasing physical activity.
Correct Answer: C
Rationale: The correct answer is C: Increasing salt intake. Salt intake can worsen hypertension by causing water retention and increasing blood pressure. Limiting caffeine intake (A) and increasing physical activity (D) are beneficial for managing hypertension. Consuming more fruits and vegetables (B) is also recommended as they are part of a healthy diet that can help lower blood pressure. Overall, educating the patient to avoid increasing salt intake is crucial in managing hypertension effectively.
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 providing education to a patient with hypertension. Which of the following statements by the patient indicates the need for further education?
- A. I will limit my sodium intake.
- B. I will monitor my blood pressure regularly.
- C. I can stop taking my medication once my blood pressure is normal.
- D. I will exercise regularly to improve my health.
Correct Answer: C
Rationale: The correct answer is C. This statement indicates a misunderstanding because stopping medication once blood pressure is normal can lead to a relapse of hypertension. Step 1: Medication management is crucial for long-term control of hypertension. Step 2: Stopping medication abruptly can cause blood pressure to rise again. Step 3: Regular monitoring, limiting sodium intake, and exercising are all important aspects of hypertension management. Summary: Choices A, B, and D demonstrate good understanding of hypertension management, while choice C shows a need for further education on the importance of continued medication use.
While auscultating for heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?
- A. Document the findings on the patient's record.
- B. Wait 10 minutes, and auscultate the heart again.
- C. Ask another nurse to double-check the finding.
- D. Ask the patient to take deep breaths and check for changes in their physical condition.
Correct Answer: A
Rationale: The correct answer is A because documenting the findings is essential for accurate patient care and communication among healthcare professionals. By documenting the unfamiliar sound heard during auscultation, the nurse ensures that the information is recorded for future reference and potential follow-up assessments or interventions. Waiting 10 minutes (B) may not address the immediate need for documentation. Asking another nurse to double-check (C) may be helpful but does not address the importance of documenting the finding. Asking the patient to take deep breaths (D) is not the appropriate next step when an unfamiliar heart sound is detected; documentation is crucial before further assessment or intervention.
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.