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The nurse is performing a review of systems on a 76-year-old patient. Which of the following statements is correct for this situation?
- A. The questions asked are identical for all ages.
- B. The interviewer will start incorporating different questions for patients 70 years of age and older.
- C. Additional questions are reflective of the normal effects of aging.
- D. At this age, a review of systems is not necessary; just focus on current problems.
Correct Answer: C
Rationale: Rationale: Choice C is correct as additional questions in a review of systems for a 76-year-old patient should address age-related changes. This allows for better assessment of potential health issues specific to older adults. Choice A is incorrect as questions may vary based on age. Choice B is incorrect as age alone does not dictate question changes. Choice D is incorrect as a review of systems is important at all ages for comprehensive patient assessment.
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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 nurse is teaching a patient about managing asthma. Which of the following statements by the patient indicates a need for further education?
- A. I will take my rescue inhaler only during an asthma attack.
- B. I should avoid exposure to allergens that trigger my symptoms.
- C. I will use my inhaler before exercise to prevent symptoms.
- D. I should always carry my inhaler with me.
Correct Answer: A
Rationale: The correct answer is A: I will take my rescue inhaler only during an asthma attack. This statement indicates a need for further education because using a rescue inhaler only during an asthma attack is not the correct way to manage asthma. The purpose of a rescue inhaler is to provide quick relief during an asthma attack, but it should also be used as a preventive measure before exposure to known triggers or before exercise to prevent symptoms. Options B, C, and D all demonstrate good understanding of asthma management by indicating the importance of avoiding triggers, using the inhaler preventively, and carrying the inhaler at all times for emergency situations.
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.
While working in the surgical unit, the nurse notices that a patient speaks a language that she cannot understanThe nurse is aware that the hospital has a number of postoperative instructions, translated videos, and brochures in this patient's language, in addition to having a translator on staff. These are all examples of:
- A. language services that are available to all admitted patients.
- B. the standards for cultural and linguistically appropriate services.
- C. ways of addressing diverse communication needs.
- D. efforts to improve patient satisfaction and care
Correct Answer: B
Rationale: The correct answer is B: the standards for cultural and linguistically appropriate services. The rationale is as follows:
1. Cultural and linguistically appropriate services ensure that patients receive care that is respectful of and responsive to their cultural and linguistic needs.
2. Having translated materials and a translator on staff aligns with these standards by providing access to healthcare information in the patient's language.
3. By offering postoperative instructions and resources in the patient's language, the hospital is promoting effective communication and understanding.
4. These services aim to reduce language barriers, improve patient outcomes, and enhance the overall quality of care.
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following signs of an exacerbation?
- A. Increased sputum production.
- B. Decreased respiratory rate.
- C. Low blood pressure.
- D. High fever.
Correct Answer: A
Rationale: 1. Increased sputum production is a sign of COPD exacerbation due to worsening inflammation and mucus production.
2. Decreased respiratory rate is not typical in COPD exacerbation as patients often experience increased respiratory effort.
3. Low blood pressure is not a common sign of COPD exacerbation and is more likely related to other conditions or medications.
4. High fever is not a typical sign of COPD exacerbation and could indicate an infection or other underlying issue.