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A nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?
- A. 108/60 mm Hg
- B. 128/88 mm Hg
- C. 154/96 mm Hg
- D. 164/104 mm Hg
Correct Answer: C
Rationale: The correct answer is C (154/96 mm Hg) for stage 1 hypertension. Stage 1 hypertension is defined as systolic blood pressure ranging from 130-139 mm Hg or diastolic blood pressure ranging from 80-89 mm Hg. Option C falls within this range, making it the correct choice. Option A (108/60 mm Hg) is normal blood pressure. Option B (128/88 mm Hg) is prehypertension. Option D (164/104 mm Hg) falls within the stage 2 hypertension range, which is higher than stage 1 hypertension.
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A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?
- A. Inability to regulate body temperature
- B. Bradycardia
- C. Visual disturbances
- D. Inability to perceive sound
Correct Answer: A
Rationale: The correct answer is A: Inability to regulate body temperature. The hypothalamus plays a crucial role in regulating body temperature. Surgery near this area can disrupt its function, leading to potential problems in thermoregulation. The nurse should monitor the client for signs of hyperthermia or hypothermia. Bradycardia (choice B) is more related to dysfunction in the cardiovascular system, not typically affected by surgery near the hypothalamus. Visual disturbances (choice C) and inability to perceive sound (choice D) are more associated with areas of the brain responsible for processing sensory information, not specifically linked to the hypothalamus.
A nurse in a clinic is reinforcing teaching with a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification?
- A. I'll sit with my knees lower than my hips.'
- B. I'll do exercises that strengthen my abdominal muscles.'
- C. I'll wear low-heeled shoes from now on.'
- D. I'll carry heavy objects close to my body.'
Correct Answer: A
Rationale: The correct answer is A: "I'll sit with my knees lower than my hips." This statement indicates a misunderstanding as it can actually contribute to low back pain. Sitting with knees lower than hips can increase pressure on the lower back. The correct sitting posture to prevent low back pain is to have knees at or slightly above hip level. This helps maintain the natural curve of the spine.
Explanation for other choices:
B: "I'll do exercises that strengthen my abdominal muscles." - Correct, as strong core muscles can help support the lower back.
C: "I'll wear low-heeled shoes from now on." - Correct, as high heels can alter posture and contribute to back pain.
D: "I'll carry heavy objects close to my body." - Correct, as this reduces strain on the back when lifting.
A nurse is assisting with a presentation at a senior center regarding age-related changes. Which of the following should the nurse include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. With aging, there is a natural decline in muscle mass known as sarcopenia. The nurse should include this because it is a common age-related change that can affect strength and mobility in older adults. Decreased muscle mass can lead to frailty and increased risk of falls. Thickened vertebral disks (B) are not a typical age-related change; instead, they tend to degenerate and become thinner. Decreased chest width (C) is not a significant age-related change and may vary among individuals. Increased force of isometric contractions (D) is not a typical age-related change; in fact, muscle strength tends to decrease with age, leading to reduced force production.
A nurse is talking with a client who is beginning a program of moderate exercise. When the nurse reminds the client of the importance of doing warm-up exercises, the client asks why. Which of the following reasons should the nurse give?
- A. Stabilizes body temperature
- B. Enhances relaxation
- C. Reduces the risk of injury
- D. Readjusts to baseline function
Correct Answer: C
Rationale: The correct answer is C: Reduces the risk of injury. Warm-up exercises help increase blood flow to muscles, making them more flexible and responsive. This reduces the risk of muscle strains and injuries during exercise. Choice A is incorrect because while warm-up exercises may help regulate body temperature during exercise, that is not the primary reason for warm-ups. Choice B is incorrect as the primary purpose of warm-up exercises is not necessarily to enhance relaxation. Choice D is incorrect as warm-up exercises do not specifically readjust to baseline function; they prepare the body for exercise.
A nurse is preparing to perform wound care and remove staples from a client's surgical incision following a hip replacement. Identify the sequence the nurse should follow. (Move the steps of staple removal into the box on the right, placing them in the selected order of performance. All steps must be used.)
- A. Remove every other staple.
- B. Wipe cleansing solution directly over the surgical incision.
- C. Remove remaining staples.
- D. Remove the wound dressing.
- E. Clean the skin along the sides of the incision.
Correct Answer: D, E, A, C, B
Rationale: First, remove the wound dressing to expose the incision. Then, clean the skin along the sides to reduce infection risk. Next, remove every other staple to maintain stability before removing the remaining ones. Finally, wipe cleansing solution to keep the site clean.