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A nurse is teaching a patient with hypertension about lifestyle modifications. Which of the following statements by the patient indicates proper understanding?
- A. I will monitor my blood pressure regularly.
- B. I will take my medication as prescribed.
- C. I can stop taking my medication if my blood pressure is normal.
- D. I will limit my alcohol intake and reduce sodium intake.
Correct Answer: D
Rationale: The correct answer is D, as limiting alcohol and reducing sodium intake are crucial lifestyle modifications for managing hypertension. Alcohol can raise blood pressure, while excess sodium can increase fluid retention and elevate blood pressure. Monitoring blood pressure regularly (choice A) is important but alone does not indicate understanding of lifestyle modifications. Taking medication as prescribed (choice B) is essential but does not address lifestyle changes. Stopping medication if blood pressure is normal (choice C) is dangerous, as hypertension often requires ongoing treatment. In summary, choice D addresses key lifestyle modifications necessary for managing hypertension, while the other choices do not fully demonstrate understanding of proper management strategies.
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Which of the following statements represents subjective data about the patient's skin?
- A. Skin dry in appearance
- B. No obvious lesions
- C. Denies colour change
- D. Lesion noted lateral aspect right arm
Correct Answer: C
Rationale: The correct answer is C because it indicates that the information was provided directly by the patient and is based on their perception or feeling. Subjective data is based on the patient's experiences and cannot be observed or measured by others. Choices A, B, and D are all objective data as they can be observed or measured by healthcare providers. Choice A describes a visible characteristic of the skin, choice B indicates absence of observable lesions, and choice D reports an observed lesion on a specific location of the skin. Therefore, choice C is the only option that reflects subjective data about the patient's skin.
Which of the following are considered second-level priority problems?
- A. Low self-esteem.
- B. Lack of knowledge.
- C. Abnormal laboratory values.
- D. Severely abnormal vital signs.
Correct Answer: C
Rationale: The correct answer is C: Abnormal laboratory values. Second-level priority problems are those that are important to the patient's health but may not be life-threatening. Abnormal laboratory values fall into this category as they indicate an underlying health issue that needs attention. Low self-esteem (A) and lack of knowledge (B) are typically considered third-level priority problems, as they do not pose an immediate threat to the patient's health. Severely abnormal vital signs (D) are first-level priority problems, as they indicate an acute and potentially life-threatening situation that requires immediate intervention. Therefore, the correct answer is C as it aligns with the definition of second-level priority problems.
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should encourage the patient to:
- A. Avoid deep breathing exercises to prevent pain.
- B. Take shallow breaths to minimize pain.
- C. Perform deep breathing exercises to prevent pneumonia.
- D. Limit mobility to avoid stress on the surgical site.
Correct Answer: C
Rationale: Step 1: Post-operative patients are at risk for developing pneumonia due to decreased lung expansion and secretion retention.
Step 2: Deep breathing exercises help improve lung expansion and prevent pneumonia.
Step 3: Therefore, encouraging the patient to perform deep breathing exercises is essential.
Summary:
- A: Avoiding deep breathing exercises is incorrect as it can lead to respiratory complications.
- B: Taking shallow breaths can worsen lung function and increase the risk of pneumonia.
- D: Limiting mobility can lead to complications like blood clots and pneumonia.
A nurse is teaching a patient about managing chronic pain. Which of the following strategies should the nurse emphasize?
- A. Increasing activity to improve function.
- B. Using medications only when absolutely necessary.
- C. Implementing physical therapy and exercises.
- D. Using complementary therapies such as meditation and relaxation.
Correct Answer: C
Rationale: The correct answer is C: Implementing physical therapy and exercises. This is crucial for managing chronic pain as it helps improve strength, flexibility, and overall function. Physical therapy can also address underlying issues contributing to pain. Choice A could worsen pain if not done appropriately. Choice B may be necessary but should not be the sole approach. Choice D can be beneficial but may not address the root cause of pain like physical therapy does.
The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which of the following would be the next appropriate action?
- A. Establishing priorities
- B. Identifying expected outcomes
- C. Evaluating the individual's condition and comparing actual outcomes with expected outcomes
- D. Interpreting data, identifying clusters of cues, and making inferences
Correct Answer: C
Rationale: The next appropriate action is to evaluate the individual's condition and compare actual outcomes with expected outcomes (Choice C). This step is crucial in determining the effectiveness of the implemented interventions in addressing the nursing diagnosis of acute pain. By evaluating the individual's condition, the nurse can assess whether the interventions have been successful in alleviating the pain. Comparing actual outcomes with expected outcomes helps in identifying any discrepancies and adjusting the plan of care accordingly to ensure optimal patient outcomes.
Establishing priorities (Choice A) is important but would come before implementing interventions. Identifying expected outcomes (Choice B) is necessary before implementing interventions but does not directly address the need for evaluation. Interpreting data and making inferences (Choice D) is part of the assessment phase and not the next appropriate action after implementing interventions.