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The nurse is assessing a 75-year-old male patient. At the beginning of the mental status portion of the assessment, the nurse expects that this patient:
- A. Will have no decrease in any of his abilities, including response time.
- B. Will have difficulty on tests of remote memory because this typically decreases with age.
- C. May take a little longer to respond, but his general knowledge and abilities should not have declined.
- D. Will have had a decrease in his response time because of language loss and a decrease in general knowledge.
Correct Answer: C
Rationale: Rationale for Correct Answer C:
- As individuals age, it is normal to experience a slight decline in cognitive abilities, such as response time.
- However, general knowledge and abilities are usually well-preserved in older adults.
- It is expected that the 75-year-old patient may take a little longer to respond due to age-related changes but should not have a significant decline in general knowledge.
Summary of Incorrect Choices:
- Choice A is incorrect because it is unrealistic to expect no decrease in any abilities with age.
- Choice B is incorrect because while remote memory may decline with age, it is not a universal expectation for all older adults.
- Choice D is incorrect as it inaccurately attributes language loss and a decrease in general knowledge to all older adults.
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A nurse is teaching a patient about managing high cholesterol. Which of the following dietary changes would be most beneficial for lowering cholesterol?
- A. Increasing intake of saturated fats.
- B. Decreasing intake of dietary fiber.
- C. Decreasing intake of trans fats.
- D. Increasing intake of processed sugars.
Correct Answer: C
Rationale: The correct answer is C: Decreasing intake of trans fats. Trans fats are known to increase LDL cholesterol levels, which are considered "bad" cholesterol. By reducing trans fats in the diet, the patient can lower their cholesterol levels. Saturated fats (choice A) can also increase LDL cholesterol, so increasing intake is not beneficial. Dietary fiber (choice B) helps lower cholesterol by binding to cholesterol in the digestive system, so decreasing intake would not be beneficial. Processed sugars (choice D) do not directly impact cholesterol levels, so increasing intake would not help lower cholesterol. Overall, choosing option C is the most effective dietary change for managing high cholesterol.
A nurse is caring for a patient who is post-operative following hip replacement surgery. Which of the following should be included in the nursing care plan to prevent complications?
- A. Encouraging the patient to avoid physical activity for several weeks.
- B. Administering pain medication only when requested by the patient.
- C. Monitoring the patient for signs of infection and deep vein thrombosis.
- D. Providing education on safe lifting techniques.
Correct Answer: C
Rationale: The correct answer is C because monitoring the patient for signs of infection and deep vein thrombosis is crucial in preventing complications post-hip replacement surgery. Infections can lead to serious complications, while deep vein thrombosis can result in blood clots that can be life-threatening. By closely monitoring for these signs, the nurse can intervene early and prevent further complications.
Choice A is incorrect because complete avoidance of physical activity can lead to other complications such as muscle atrophy and delayed recovery. Choice B is incorrect because pain management should be proactive to prevent unnecessary suffering. Choice D, while important, is not directly related to preventing complications such as infection and deep vein thrombosis.
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following interventions?
- A. Administering supplemental oxygen as needed.
- B. Encouraging regular physical activity.
- C. Administering antibiotics regularly.
- D. Providing increased fluid intake.
Correct Answer: A
Rationale: The correct answer is A: Administering supplemental oxygen as needed. This is the priority intervention for a patient with COPD because it helps improve oxygenation and relieve respiratory distress, which is the main concern in COPD. Supplemental oxygen also helps reduce the workload on the heart and other organs. Encouraging physical activity (B) is important for overall health but may not be the priority in acute exacerbations. Administering antibiotics regularly (C) is not necessary unless there is a documented infection. Providing increased fluid intake (D) is important for maintaining hydration but is not the priority intervention in this case.
A nurse is caring for a patient with a history of chronic kidney disease (CKD). The nurse should monitor for which of the following complications?
- A. Hyperkalemia.
- B. Hypokalemia.
- C. Hyperglycemia.
- D. Hypercalcemia.
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In CKD, kidneys struggle to excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac arrhythmias. Hypokalemia (B) is unlikely in CKD due to impaired potassium excretion. Hyperglycemia (C) is more commonly associated with diabetes rather than CKD. Hypercalcemia (D) is not a typical complication of CKD; instead, patients with CKD often experience low calcium levels.
A nurse is caring for a patient who has undergone a knee replacement. The nurse should encourage which of the following to promote recovery?
- A. Strict bed rest for the first 48 hours.
- B. Ambulation as soon as possible after surgery.
- C. Limiting physical activity for 2 weeks post-op.
- D. Prolonged use of the affected leg in a cast.
Correct Answer: B
Rationale: The correct answer is B: Ambulation as soon as possible after surgery. Ambulation helps prevent complications like blood clots and aids in circulation and muscle strength. Bed rest can lead to stiffness and decrease in range of motion. Limiting physical activity delays recovery. Prolonged use of a cast can hinder mobility and delay rehabilitation.