Nokea
An adult blood pressure reading of 120/80 mm Hg is:
- A. Prehypertension
- B. Hypotensive
- C. Normal
- D. Hypertensive
Correct Answer: C
Rationale: A blood pressure reading of 120/80 mm Hg is considered normal according to widely accepted medical guidelines, such as those from the American Heart Association. The systolic pressure (120 mm Hg) represents the force when the heart contracts, and the diastolic pressure (80 mm Hg) reflects the pressure when the heart is at rest. Normal blood pressure is typically defined as systolic less than 120 mm Hg and diastolic less than 80 mm Hg, making Normal, correct. Prehypertension, applies to readings like 120-129/<80 mm Hg, but 120/80 exceeds this slightly yet remains within normal limits in many contexts. Hypotensive, indicates low blood pressure (e.g., below 90/60 mm Hg), which 120/80 clearly is not. Hypertensive, refers to high blood pressure (e.g., 130/80 mm Hg or higher), which this reading does not meet. Therefore, C is the accurate answer based on standard classifications.
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When using an otoscope to examine a patient, the nurse:
- A. Uses a broad speculum to visualize sinuses.
- B. Examines the inner ear structures.
- C. Directs light onto the tympanic membrane.
- D. Checks for external lesions with the light.
Correct Answer: C
Rationale: The correct answer is C because when using an otoscope, the nurse should direct light onto the tympanic membrane (eardrum) to visualize its condition. This helps in assessing ear health and identifying any abnormalities or infections. Choice A is incorrect as an otoscope is not used to visualize sinuses. Choice B is incorrect as it refers to examining inner ear structures which is beyond the scope of an otoscope. Choice D is incorrect as external lesions are not typically assessed using an otoscope.
A 25-year-old woman presents with a complaint of a new onset of pain and swelling in her left knee. She has a history of psoriasis. What is the most likely diagnosis?
- A. Rheumatoid arthritis
- B. Osteoarthritis
- C. Psoriatic arthritis
- D. Gout
Correct Answer: C
Rationale: The correct answer is C: Psoriatic arthritis. The patient's history of psoriasis is a key clue. Psoriatic arthritis commonly affects individuals with psoriasis, presenting with joint pain and swelling. Rheumatoid arthritis (choice A) typically affects multiple joints symmetrically. Osteoarthritis (choice B) is more common in older individuals and does not have a strong association with psoriasis. Gout (choice D) is characterized by sudden, severe attacks of pain, usually in the joint at the base of the big toe, and is not typically associated with psoriasis.
The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview?
- A. I sleep like a baby
- B. I have no health problems
- C. I never did too good in school
- D. I am not currently taking any medications
Correct Answer: C
Rationale: The correct answer is C: "I never did too good in school." This statement indicates potential underlying issues like learning disabilities or lack of education, affecting the patient's understanding of health information. The nurse should explore this further to assess the patient's health literacy. Choices A, B, and D are less critical as they do not directly impact the patient's health status or the interview process.
A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. 'I'll be sleeping great, and then I wake up and feel like I can't get my breath.' The nurse's best response to this would be:
- A. When was your last electrocardiogram?'
- B. It's probably because it's been so hot at night.'
- C. Do you have any history of problems with your heart?'
- D. Have you had a recent sinus infection or upper respiratory infection?'
Correct Answer: C
Rationale: The correct answer is C: 'Do you have any history of problems with your heart?'
Rationale:
1. Difficulty sleeping and waking up feeling breathless can be indicative of cardiac issues like heart failure or arrhythmias.
2. Asking about a history of heart problems is crucial to assess the patient's risk factors and determine the need for further cardiac evaluation.
3. This response shows the nurse's understanding of the potential seriousness of the symptoms and the need to investigate cardiac health.
Summary:
- Option A (Electrocardiogram) is not the best initial response as it jumps to a specific test without gathering more information.
- Option B (Hot at night) dismisses the symptoms without considering underlying health issues.
- Option D (Sinus or respiratory infection) does not address the potential cardiac cause of the symptoms.
During a neurological assessment, the nurse tests cranial nerve VII. What is the primary function of this nerve?
- A. Hearing and balance.
- B. Facial movements and expression.
- C. Swallowing and speech.
- D. Eye movement.
Correct Answer: B
Rationale: The correct answer is B: Facial movements and expression. Cranial nerve VII, also known as the facial nerve, primarily controls facial muscles responsible for facial expressions, such as smiling and frowning. It also innervates the muscles involved in closing the eyes and controlling the forehead and mouth movements. Other choices are incorrect because cranial nerve VII is not primarily responsible for hearing and balance (A), swallowing and speech (C), or eye movement (D). The key function of cranial nerve VII lies in its role in facial movements and expressions.