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Which of the following statements about mental health assessment is true?
- A. The mental health assessment diagnoses specific psychiatric disorders.
- B. Mental disorders occur in response to everyday life stressors.
- C. Mental status is inferred through assessment of an individual's behaviours.
- D. Mental health can be assessed directly, just like the characteristics of any other body system (e.g., cardiac and breath sounds).
Correct Answer: C
Rationale: The correct answer is C because mental status is indeed inferred through assessment of an individual's behaviors. Mental health assessment involves observing and evaluating a person's thoughts, emotions, behaviors, and overall mental functioning to determine their mental status. This includes assessing speech, mood, cognition, and perception. Choices A, B, and D are incorrect because:
A: Mental health assessment does not solely focus on diagnosing specific psychiatric disorders; it is a broader evaluation of an individual's mental well-being.
B: Mental disorders can result from a variety of factors beyond everyday life stressors, such as genetic predisposition or traumatic experiences.
D: Mental health assessment is more complex than assessing physical characteristics and involves subjective interpretation of behaviors rather than direct observation like physical assessments.
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A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should encourage the patient to perform which of the following exercises to prevent complications?
- A. Quadriceps setting exercises.
- B. Leg lifts with weights.
- C. Isometric muscle contractions.
- D. Active range-of-motion exercises.
Correct Answer: A
Rationale: The correct answer is A: Quadriceps setting exercises. These exercises help prevent complications by strengthening the quadriceps muscles, which are crucial for knee stability and joint support post-surgery. They also aid in preventing muscle atrophy and promoting blood circulation. Leg lifts with weights (B) may strain the knee joint, leading to complications. Isometric muscle contractions (C) involve static muscle contractions and do not provide the necessary range of motion needed post-knee surgery. Active range-of-motion exercises (D) may be beneficial but should be performed after quadriceps setting exercises to avoid unnecessary strain on the knee joint.
A 60-year-old woman is undergoing a mammogram. The nurse explains that the procedure is done to:
- A. Detect any abnormal growths or tumors in the breast tissue.
- B. Identify changes in hormone levels.
- C. Evaluate lung function related to breast cancer.
- D. Assess for signs of osteoporosis.
Correct Answer: A
Rationale: The correct answer is A because mammograms are specifically designed to detect abnormal growths or tumors in the breast tissue, particularly in the early stages of breast cancer. This is crucial for early detection and effective treatment.
Choice B is incorrect because mammograms are not used to identify changes in hormone levels. Choice C is incorrect because mammograms do not evaluate lung function related to breast cancer. Choice D is incorrect because mammograms do not assess for signs of osteoporosis; a bone density scan is typically used for that purpose.
A nurse is caring for a patient with a history of hypertension. The nurse should prioritize which of the following interventions?
- A. Administering antihypertensive medication as prescribed.
- B. Encouraging weight loss.
- C. Monitoring blood pressure regularly.
- D. Promoting a low-sodium diet.
Correct Answer: A
Rationale: The correct answer is A: Administering antihypertensive medication as prescribed. This is the priority intervention because it directly addresses the patient's hypertension, which is a critical condition that needs immediate management to prevent complications. Encouraging weight loss (B), monitoring blood pressure (C), and promoting a low-sodium diet (D) are all important aspects of managing hypertension. However, administering antihypertensive medication takes precedence as it directly targets lowering blood pressure and reducing the risk of cardiovascular events. Weight loss, monitoring, and dietary changes are important for long-term management but may not provide immediate control of hypertension compared to medication.
A patient with diabetes is experiencing a hypoglycemic episode. Which of the following is the nurse's first priority in this situation?
- A. Administering insulin.
- B. Providing a source of fast-acting carbohydrate.
- C. Checking the patient's blood glucose level.
- D. Contacting the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In a hypoglycemic episode, the priority is to raise the blood sugar quickly to prevent further complications. Fast-acting carbohydrates such as glucose tablets or orange juice can rapidly increase blood sugar levels. Administering insulin (choice A) can further lower blood sugar, checking blood glucose levels (choice C) may delay treatment, and contacting the healthcare provider (choice D) is not necessary in the immediate management of hypoglycemia.
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
- A. Ask the patient to take deep breaths to relax the abdominal musculature.
- B. Consider this a normal finding, and proceed with the abdominal assessment.
- C. Use less force to percuss over the abdomen.
- D. Use more force to percuss over the abdomen.
Correct Answer: C
Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.