Nokea
An example of objective information obtained during the physical assessment includes the patient's:
- A. history of allergies.
- B. use of medications at home.
- C. last menstrual period.
- D. 2 cm x 5 cm scar present on the right forearm.
Correct Answer: D
Rationale: The correct answer is D because the presence of a physical characteristic like a scar is an objective finding that can be directly observed and measured during a physical assessment. This information is not subject to interpretation or bias. In contrast, choices A, B, and C involve subjective information that relies on the patient's report or memory, making them less reliable and objective. History of allergies (A) and use of medications (B) are subjective and based on the patient's self-report, while last menstrual period (C) is also subjective and may not always be accurate. Therefore, choice D is the only objective piece of information among the options provided.
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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 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.
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?' The nurse tells her:
- A. They are signs of decreased hematocrit related to anemia.
- B. They are due to destruction of melanin in your skin due to exposure to the sun.
- C. They are clusters of melanocytes that appear after prolonged sun exposure.
- D. They are areas of hyperpigmentation related to decreased perfusion and vasoconstriction.
Correct Answer: C
Rationale: The correct answer is C because the small, flat, brown macules described are consistent with lentigines (commonly known as age or liver spots), which are clusters of melanocytes that appear after prolonged sun exposure. This explanation directly addresses the patient's question about the cause of the spots and is supported by the clinical presentation.
Choice A is incorrect because decreased hematocrit related to anemia would not cause these specific skin changes. Choice B is incorrect as destruction of melanin due to sun exposure would result in lighter spots, not dark brown macules. Choice D is incorrect because hyperpigmentation related to decreased perfusion and vasoconstriction would present differently and not primarily on sun-exposed areas like the arms and hands.
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should educate the patient to avoid which of the following to prevent hip dislocation?
- A. Crossing the legs at the knees.
- B. Sitting with the feet flat on the floor.
- C. Sleeping on the affected side.
- D. Using assistive devices for ambulation.
Correct Answer: A
Rationale: The correct answer is A: Crossing the legs at the knees. This position can cause hip dislocation due to the twisting motion it creates on the hip joint. When the legs are crossed at the knees, it puts stress on the hip joint, potentially leading to dislocation.
Choice B: Sitting with the feet flat on the floor is a safe position that does not put undue stress on the hip joint.
Choice C: Sleeping on the affected side can also increase the risk of hip dislocation due to the pressure and weight placed on the hip joint in this position.
Choice D: Using assistive devices for ambulation is important for stability and support, and it does not directly contribute to hip dislocation if used correctly.
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.