Nokea
A patient is post-operative following a total hip replacement. The nurse should prioritize which of the following to prevent complications?
- A. Monitoring for signs of infection.
- B. Encouraging early ambulation.
- C. Administering pain medications regularly.
- D. Providing wound care and dressing changes.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation. This is crucial post-total hip replacement to prevent complications such as blood clots, pneumonia, and muscle weakness. Early ambulation helps improve circulation, prevent stiffness, and promote faster recovery. Monitoring for infection (A) is important but not the top priority. Administering pain medications (C) and wound care (D) are essential but do not address the primary goal of preventing complications post-operatively.
You may also like to solve these questions
Which critical thinking skill helps the nurse recognize relationships among data?
- A. Validation.
- B. Clustering-related cues.
- C. Identifying gaps in data.
- D. Distinguishing relevant from irrelevant.
Correct Answer: B
Rationale: The correct answer is B: Clustering-related cues. This critical thinking skill helps the nurse recognize relationships among data by grouping related information together. This aids in identifying patterns, connections, and trends within the data, leading to a better understanding of the situation. Validation (A) involves confirming the accuracy of data, not necessarily recognizing relationships. Identifying gaps in data (C) focuses on missing information rather than relationships among existing data. Distinguishing relevant from irrelevant (D) is important but does not directly address recognizing relationships among data. In summary, clustering-related cues (B) is the most relevant skill for recognizing relationships among data in critical thinking.
The nurse has just started an assessment of the newborn child of a woman of Vietnamese origin. Considering the mother's cultural background, which of the following statements about this examination is true? The mother:
- A. Will be offended if the infant's fontanelles are examined.
- B. Will be offended if the infant's diaper area is touched during the examination.
- C. Would prefer to have the results of the examination communicated directly to her husband.
- D. Would prefer to receive written report about her child's growth and development, rather than a verbal one.
Correct Answer: A
Rationale: The correct answer is A because in Vietnamese culture, touching or examining the fontanelles (soft spots on a baby's head) is considered disrespectful and potentially harmful. This is due to the belief that the fontanelles are fragile and touching them can impact the baby's health. It is crucial for the nurse to respect and be sensitive to the cultural beliefs and practices of the mother to establish trust and provide culturally competent care.
Choice B is incorrect because there is no specific cultural taboo in Vietnamese culture about touching the infant's diaper area during examination. Choice C is incorrect as assuming that the husband should be the primary communicator of medical information goes against the principle of patient autonomy. Choice D is incorrect as there is no indication that Vietnamese mothers prefer written reports over verbal communication regarding their child's growth and development.
Which of the following statements best describes the Montreal Cognitive Assessment (MoCA) examination?
- A. Scores below 30 indicate cognitive impairment.
- B. It is a good tool to evaluate mood and thought processes.
- C. It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
- D. It is useful for an initial evaluation of mental health. Additional tools are needed to evaluate changes in cognition over time.
Correct Answer: C
Rationale: The correct answer is C because the Montreal Cognitive Assessment (MoCA) is specifically designed to detect delirium and dementia and differentiate these conditions from psychiatric mental illness. It assesses various cognitive domains such as memory, attention, language, and visuospatial abilities. Scores below the normal range on the MoCA can indicate cognitive impairment related to delirium or dementia.
Choice A is incorrect because a score below 30 on the MoCA does not necessarily indicate cognitive impairment; it depends on the individual's baseline and education level.
Choice B is incorrect because the MoCA primarily focuses on cognitive function rather than mood and thought processes.
Choice D is incorrect because while the MoCA can be used for initial evaluation of cognitive function, it is not sufficient for evaluating changes over time. Additional tools and assessments are needed for longitudinal monitoring of cognitive changes.
A 16-year-old boy has just been admitted for overnight observation after being in an automobile accident. What is the nurse's best approach to communicating with him?
- A. Use periods of silence to communicate respect for him.
- B. Be totally honest with him, even if the information is unpleasant.
- C. Tell him that everything that is discussed will be kept totally confidential.
- D. Use slang language when possible to help him open up.
Correct Answer: B
Rationale: The correct answer is B: Be totally honest with him, even if the information is unpleasant. This is the best approach because honesty builds trust and credibility, crucial in a healthcare setting. It allows the teenager to make informed decisions about his care and fosters a therapeutic relationship.
Explanation for why the other choices are incorrect:
A: Using periods of silence may be misinterpreted as indifference or lack of engagement.
C: Promising total confidentiality may not be feasible in healthcare settings and could lead to potential harm if critical information needs to be shared with others for the patient's safety.
D: Using slang language may come across as unprofessional and may hinder effective communication and understanding between the nurse and the patient.
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.