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A nurse is caring for a patient with a history of hypertension. The nurse should educate the patient to monitor for which of the following complications?
- A. Severe headaches and blurred vision.
- B. Weight loss and dizziness.
- C. Increased appetite and tremors.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A: Severe headaches and blurred vision. Hypertension can lead to complications such as hypertensive crisis, causing symptoms like severe headaches and blurred vision due to increased pressure in the blood vessels. This can indicate a serious health issue requiring immediate medical attention. Weight loss and dizziness (B), increased appetite and tremors (C), and nausea and vomiting (D) are not typically associated with hypertension complications. It's crucial for the nurse to educate the patient on recognizing these signs to prevent further health risks.
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The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess skin temperature?
- A. Palpation
- B. Auscultation
- C. Inspection
- D. Use of a thermometer
Correct Answer: A
Rationale: The correct answer is A: Palpation. Palpation involves using the hands to touch and feel the skin to assess its temperature accurately. This technique allows the nurse to detect variations in temperature more effectively compared to visual inspection (Choice C) or listening with a stethoscope (Choice B). Using a thermometer (Choice D) may also provide a precise measurement, but palpation allows for a more comprehensive assessment of skin temperature by considering factors such as localized warmth or coolness.
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.
A 45-year-old woman is at the clinic for a mental health assessment. When giving her the Four Unrelated Words Test, the nurse would be concerned if the patient:
- A. Could not give four unrelated words within 5 minutes.
- B. Could not give four unrelated words within 30 seconds.
- C. Could not recall four unrelated words after a 30-minute delay.
- D. Could not recall four unrelated words after a 60-minute delay.
Correct Answer: C
Rationale: The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall.
A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task.
B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue.
D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should educate the patient to avoid which of the following to prevent hip dislocation?
- A. Crossing the legs at the knees.
- B. Sitting with the feet flat on the floor.
- C. Sleeping on the affected side.
- D. Using assistive devices for ambulation.
Correct Answer: A
Rationale: The correct answer is A: Crossing the legs at the knees. This position can cause hip dislocation due to the twisting motion it creates on the hip joint. When the legs are crossed at the knees, it puts stress on the hip joint, potentially leading to dislocation.
Choice B: Sitting with the feet flat on the floor is a safe position that does not put undue stress on the hip joint.
Choice C: Sleeping on the affected side can also increase the risk of hip dislocation due to the pressure and weight placed on the hip joint in this position.
Choice D: Using assistive devices for ambulation is important for stability and support, and it does not directly contribute to hip dislocation if used correctly.
A nurse is teaching a patient with chronic kidney disease (CKD) about dietary modifications. Which of the following statements by the patient indicates proper understanding?
- A. I should limit my sodium intake and increase my potassium intake.
- B. I should avoid eating foods high in potassium.
- C. I can eat as much protein as I want.
- D. I should drink fluids freely without restriction.
Correct Answer: B
Rationale: Rationale:
B is correct because patients with CKD often have difficulty excreting potassium, so limiting high potassium foods is crucial to prevent hyperkalemia. A is incorrect because increasing potassium intake is not recommended. C is incorrect as excessive protein intake can worsen kidney function. D is incorrect because CKD patients typically have fluid restrictions to prevent fluid overload and electrolyte imbalances.