A nurse is assessing a patient with a history of hypertension. Which of the following findings would be most concerning?

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.

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.

Correct Answer: A

Rationale: The correct answer is A because all aspects of mental health in children are indeed interrelated. Mental health encompasses various components such as emotional, social, and psychological well-being, which are interconnected and influence each other. Understanding and assessing mental health in children require considering the holistic picture. Choice B is incorrect because children are not inherently labile and unstable until the age of 2 years. Choice C is incorrect as children's mental health is influenced by various factors beyond just their parents' mental health. Choice D is incorrect because mental health assessment in children can be done using age-appropriate methods even before they develop the ability to concentrate.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation and use of compression stockings. This intervention is crucial post-hip replacement to prevent complications such as blood clots and muscle weakness. Early ambulation helps prevent blood clots by promoting circulation, and compression stockings further aid in preventing deep vein thrombosis. Pain medication (A) is important but not the priority in preventing complications. Providing nutritional support (C) is also important but does not directly prevent post-operative complications. Monitoring for signs of infection (D) is essential but not as immediate as promoting early ambulation to prevent complications.

Correct Answer: A

Rationale: The correct answer is A: Crossing the legs at the knees. This position can cause hip dislocation due to the twisting motion it creates on the hip joint. When the legs are crossed at the knees, it puts stress on the hip joint, potentially leading to dislocation. Choice B: Sitting with the feet flat on the floor is a safe position that does not put undue stress on the hip joint. Choice C: Sleeping on the affected side can also increase the risk of hip dislocation due to the pressure and weight placed on the hip joint in this position. Choice D: Using assistive devices for ambulation is important for stability and support, and it does not directly contribute to hip dislocation if used correctly.

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.

Correct Answer: A

Rationale: The correct answer is A: Hypertension. In end-stage renal disease, the kidneys are no longer able to regulate blood pressure effectively, leading to hypertension. This can increase the risk of cardiovascular complications. Monitoring for hypertension is crucial in these patients. Rationale for why the other choices are incorrect: B: Hyperglycemia is more commonly associated with diabetes rather than end-stage renal disease. C: Hypothyroidism is a separate condition not directly related to end-stage renal disease. D: Hypokalemia may occur in some cases of renal disease, but hypertension is a more common and critical concern in end-stage renal disease.

Correct Answer: A

Rationale: The correct answer is A because in Vietnamese culture, touching or examining the fontanelles (soft spots on a baby's head) is considered disrespectful and potentially harmful. This is due to the belief that the fontanelles are fragile and touching them can impact the baby's health. It is crucial for the nurse to respect and be sensitive to the cultural beliefs and practices of the mother to establish trust and provide culturally competent care. Choice B is incorrect because there is no specific cultural taboo in Vietnamese culture about touching the infant's diaper area during examination. Choice C is incorrect as assuming that the husband should be the primary communicator of medical information goes against the principle of patient autonomy. Choice D is incorrect as there is no indication that Vietnamese mothers prefer written reports over verbal communication regarding their child's growth and development.

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.