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A nurse is teaching a patient with a history of hypertension about lifestyle modifications. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood pressure regularly.
- B. I will take my medication as prescribed.
- C. I can stop taking my medication once my blood pressure is normal.
- D. I will reduce my sodium intake.
Correct Answer: C
Rationale: The correct answer is C because it indicates a misunderstanding about hypertension management. Patients should continue taking medication even if blood pressure is normal to prevent future complications. Monitoring blood pressure regularly (A) is important for tracking progress. Taking medication as prescribed (B) is crucial for controlling blood pressure. Reducing sodium intake (D) helps lower blood pressure. Choice C is incorrect as stopping medication prematurely can lead to uncontrolled hypertension.
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A nurse is caring for a patient who is post-operative following a knee replacement. Which of the following should the nurse prioritize in the post-operative care plan?
- A. Pain management.
- B. Encouraging early ambulation.
- C. Administering IV antibiotics.
- D. Monitoring for signs of deep vein thrombosis.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, improves circulation, aids in lung expansion, and promotes faster recovery. Pain management is important but encouraging mobility is a priority. Administering IV antibiotics is not necessary unless there is an infection present. Monitoring for signs of deep vein thrombosis is important but encouraging ambulation is a proactive approach to prevent its occurrence.
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.
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.
The nurse is assessing mental health in children. Which of the following statements is true?
- A. All aspects of mental health in children are interrelated.
- B. Children are highly labile and unstable until the age of 2 years.
- C. Until the age of 7 years, children's mental health is largely a function of their parents' mental health.
- D. Children's mental health is impossible to assess until they develop the ability to concentrate.
Correct Answer: A
Rationale: The correct answer is A because all aspects of mental health in children are indeed interrelated. Mental health encompasses various components such as emotional, social, and psychological well-being, which are interconnected and influence each other. Understanding and assessing mental health in children require considering the holistic picture.
Choice B is incorrect because children are not inherently labile and unstable until the age of 2 years. Choice C is incorrect as children's mental health is influenced by various factors beyond just their parents' mental health. Choice D is incorrect because mental health assessment in children can be done using age-appropriate methods even before they develop the ability to concentrate.
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.