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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 providing discharge instructions to a patient who had a stroke. Which of the following statements by the patient indicates the need for further education?
- A. I will take my medications as prescribed.
- B. I will follow up with my doctor regularly.
- C. I can resume driving after a few weeks of rest.
- D. I will report any sudden changes in my vision or speech.
Correct Answer: C
Rationale: The correct answer is C. After a stroke, patients need to be evaluated by a healthcare professional before resuming driving. This is crucial to ensure the safety of the patient and others on the road. Choice A shows medication compliance, B demonstrates follow-up care, and D emphasizes monitoring symptoms, all of which are essential post-stroke. However, choice C indicates a lack of understanding about the importance of medical clearance before driving, hence the need for further education.
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.
Which of the following positions is most appropriate for performing an abdominal examination on an obese patient?
- A. Head elevated to 45 degrees
- B. Have the patient lie flat
- C. Place the patient in the supine position
- D. Position the patient on their side
Correct Answer: C
Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.
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.
A nurse is caring for a patient who has a history of myocardial infarction. The nurse should prioritize which of the following assessments?
- A. Blood pressure and heart rate.
- B. Temperature and respiratory rate.
- C. Bowel sounds and abdominal girth.
- D. Urine output and skin integrity.
Correct Answer: A
Rationale: The correct answer is A: Blood pressure and heart rate. This is crucial in assessing the cardiac function of a patient with a history of myocardial infarction. Monitoring blood pressure and heart rate helps in evaluating cardiovascular status and detecting any potential complications. Abnormal values in these parameters can indicate inadequate perfusion to the heart or other organs, which can be life-threatening.
Other choices are incorrect because:
B: Temperature and respiratory rate are important assessments but not the priority for a patient with a history of myocardial infarction.
C: Bowel sounds and abdominal girth are more relevant for gastrointestinal issues and not a priority in this scenario.
D: Urine output and skin integrity are important assessments for overall health but do not directly relate to the cardiovascular status in a patient with a history of myocardial infarction.