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Question 1 of 5
A nurse is teaching a patient with hypertension about dietary changes. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C. Drinking caffeinated beverages can potentially increase blood pressure due to their stimulant effect. Limiting caffeine intake is recommended for patients with hypertension. Statement A is correct as reducing sodium and increasing potassium intake can help lower blood pressure. Statement B is correct as processed foods and fast food are typically high in sodium and unhealthy fats, which can worsen hypertension. Statement D is correct as fruits, vegetables, and whole grains are part of a heart-healthy diet for managing hypertension.
Question 2 of 5
What is the first priority when caring for a client with a gunshot wound to the chest?
Correct Answer: C
Rationale: The correct answer is C: Apply an airtight dressing. This is the first priority because it helps prevent air from entering the chest cavity, which can cause a tension pneumothorax. A tension pneumothorax can rapidly lead to respiratory distress and cardiac arrest. Applying an airtight dressing helps stabilize the condition until further medical intervention can be provided. Incorrect choices: A: Performing needle decompression is not the first priority as it is indicated for a tension pneumothorax once it has developed, not as a preventive measure. B: Applying a sterile dressing is important but not the first priority when dealing with a gunshot wound to the chest as sealing the wound to prevent air entry is more critical. D: Monitoring the client's ECG is not the first priority in this situation as addressing the potential tension pneumothorax takes precedence over monitoring the client's heart rhythm.
Question 3 of 5
A nurse is caring for a patient who is post-operative following a total knee replacement. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. This is a priority intervention because early ambulation helps prevent complications such as blood clots and respiratory issues. It also promotes circulation and aids in the recovery process. Administering pain medication (B) is important but not the top priority. Providing wound care and dressing changes (C) is necessary but can be done after ensuring the patient's mobility. Monitoring for signs of infection (D) is also crucial, but promoting early ambulation takes precedence in this scenario to prevent complications.
Question 4 of 5
Which side effect is most likely to alter body image in a client receiving MOPP therapy for Hodgkin's disease?
Correct Answer: B
Rationale: The correct answer is B: Alopecia. MOPP therapy for Hodgkin's disease commonly causes hair loss (alopecia), which directly affects body image. This is due to the impact on a person's physical appearance, leading to changes in self-perception and confidence. Cushingoid appearance (A) is a side effect of prolonged corticosteroid use, not typically associated with MOPP therapy. Temporary or permanent sterility (C) and pathologic fractures (D) are potential side effects of other cancer treatments but are not directly related to altering body image.
Question 5 of 5
Which of the following individuals would the nurse consider at highest risk for a suicide attempt?
Correct Answer: D
Rationale: The correct answer is D because the older adult's statement about joining his wife in heaven and plan to shoot himself indicates clear intent and imminent risk. This individual has a specific plan and timeframe, making them highest risk. Choice A is incorrect because joking about death does not necessarily indicate an imminent risk of suicide. Choice B is incorrect as past suicide attempts are a risk factor, but immediate intent is more concerning. Choice C is incorrect as the adolescent's statement is concerning, but there is no specific plan or timeframe mentioned, lowering the immediate risk compared to choice D.
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