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The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess skin temperature?
- A. Palpation
- B. Auscultation
- C. Inspection
- D. Use of a thermometer
Correct Answer: A
Rationale: The correct answer is A: Palpation. Palpation involves using the hands to touch and feel the skin to assess its temperature accurately. This technique allows the nurse to detect variations in temperature more effectively compared to visual inspection (Choice C) or listening with a stethoscope (Choice B). Using a thermometer (Choice D) may also provide a precise measurement, but palpation allows for a more comprehensive assessment of skin temperature by considering factors such as localized warmth or coolness.
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A nurse is assessing a patient's hydration status. Which of the following findings would suggest dehydration?
- A. Increased urine output
- B. Decreased heart rate
- C. Dry mucous membranes
- D. Increased blood pressure
Correct Answer: C
Rationale: The correct answer is C: Dry mucous membranes. Dry mucous membranes are a common sign of dehydration as the body lacks adequate fluid. When a person is dehydrated, there is a decrease in saliva production, leading to dryness in the mouth and throat. This can be easily observed during a physical examination by looking at the patient's lips, tongue, and inside of the mouth. On the other hand, increased urine output (choice A) is a sign of adequate hydration, decreased heart rate (choice B) can be a normal response to dehydration but is not a consistent indicator, and increased blood pressure (choice D) is not typically associated with dehydration. Therefore, dry mucous membranes are the most reliable finding to suggest dehydration in a patient.
A nurse is assessing a patient with a history of hypertension. Which of the following findings would be most concerning?
- A. A blood pressure reading of 160/100 mm Hg.
- B. A blood pressure reading of 130/85 mm Hg.
- C. A blood pressure reading of 140/90 mm Hg.
- D. A blood pressure reading of 120/80 mm Hg.
Correct Answer: A
Rationale: The correct answer is A. A blood pressure reading of 160/100 mm Hg is most concerning because it falls within the hypertensive crisis range, indicating severely elevated blood pressure that requires immediate medical attention to prevent complications like stroke or heart attack. Choices B, C, and D are within the prehypertension or mild hypertension ranges and are not as immediately concerning.
Which of the following is the best choice for an opening statement with a patient who is in distress?
- A. "Nancy, my name is Mrs. C."
- B. "Hello, Mrs. H., my name is Mrs. C. It sure is cold today!"
- C. "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
- D. "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
Correct Answer: D
Rationale: The correct answer is D because it directly acknowledges the patient's distress and sets the stage for gathering essential information. By stating the need to ask questions about what happened, it shows empathy and readiness to provide help. Choice A is too formal and lacks empathy. Choice B shifts the focus away from the patient's distress. Choice C is similar to D but lacks the crucial element of acknowledging the patient's emotional state. Thus, D is the best choice for an opening statement in this scenario.
A nurse is teaching a patient with a history of hypertension about lifestyle modifications. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood pressure regularly.
- B. I will take my medication as prescribed.
- C. I can stop taking my medication once my blood pressure is normal.
- D. I will reduce my sodium intake.
Correct Answer: C
Rationale: The correct answer is C because it indicates a misunderstanding about hypertension management. Patients should continue taking medication even if blood pressure is normal to prevent future complications. Monitoring blood pressure regularly (A) is important for tracking progress. Taking medication as prescribed (B) is crucial for controlling blood pressure. Reducing sodium intake (D) helps lower blood pressure. Choice C is incorrect as stopping medication prematurely can lead to uncontrolled hypertension.
The nurse is obtaining a history from a 30-year-old male patient and is concerned about the adequacy of his health promotion activities. Which one of the following questions would be appropriate in this situation?
- A. "Do you perform testicular self-examinations?"
- B. "Have you ever noticed any pain in your testicles?"
- C. "Have you had any problems with passing urine?"
- D. "Do you have any history of sexually transmitted infection?"
Correct Answer: A
Rationale: The correct answer is A: "Do you perform testicular self-examinations?" This question is appropriate as it addresses health promotion activities specific to the patient's age and gender, promoting early detection of testicular cancer.
Explanation:
1. Testicular self-examination is a key health promotion activity for men in their 20s and 30s.
2. It encourages self-awareness and early detection of abnormalities in the testicles.
3. Testicular cancer is most common in younger men, making this question relevant.
4. Options B, C, and D are not directly related to health promotion activities for a 30-year-old male.