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.

Correct Answer: B

Rationale: Mammography is used to detect tumors in the breast tissue by taking X-ray images. Tumors can be cancerous or benign, making early detection crucial for treatment. Pain (A) is a symptom, not detected by mammography. Edema (C) is swelling caused by fluid retention, not a primary target of mammography. Epilepsy (D) is a neurological disorder, unrelated to mammography's purpose. Therefore, the correct answer is B.

Correct Answer: A

Rationale: The correct answer is A because broccoli, oranges, and dark greens are rich in essential nutrients like vitamin C, antioxidants, and phytochemicals that boost the immune system and help prevent diseases. Broccoli contains sulforaphane, which has been shown to have anti-cancer properties. Oranges are high in vitamin C, crucial for immune function. Dark greens like spinach and kale are packed with vitamins and minerals that support overall health. Choice B is incorrect because no single food can cure many diseases. Choice C is incorrect because relying solely on vitamin pills may not provide all the necessary nutrients and benefits of whole foods. Choice D is incorrect as there is no scientific evidence supporting the concept of balancing body molecules through food.

Correct Answer: A

Rationale: The correct answer is A: Body systems. This type of assessment promotes critical thinking by organizing data systematically based on different body systems, allowing for clustering of similar data and identification of patterns. Comprehensive assessments (B) may include body systems but lack the focused approach of promoting critical thinking. Head to toe assessments (C) are systematic but may not encourage clustering of data. Emergency assessments (D) prioritize immediate interventions rather than promoting critical thinking or clustering of data.

Correct Answer: D

Rationale: The correct answer is D. The nursing process consists of Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation. Assessment involves gathering data about the patient's health status. Diagnosis is the identification of the patient's health problems. Outcome Identification sets goals for resolving these problems. Planning involves developing a care plan. Implementation is the execution of the care plan. Evaluation assesses the effectiveness of the care provided. Choices A, B, and C are incorrect: A: Treatment and client outcome are not individual phases in the nursing process. B: Admission and discharge planning are not standalone phases in the nursing process. C: Expected outcome is not a phase, and assessment is missing from the sequence.

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. In an 11-12-month-old child, the inability to pull to a standing position may indicate developmental dysplasia of the hip (DDH) as it can lead to abnormal hip development. Refusal to walk (A) can be a sign of other musculoskeletal issues but not specific to DDH. Negative Trendelenburg sign (C) refers to weakness in the hip abductors and is not a specific finding for DDH. A negative Ortolani sign (D) indicates the absence of hip dislocation and is not a definitive sign of DDH at this age.

Correct Answer: A

Rationale: The correct answer is A: Use a numeric pain scale. This method allows for quantitative assessment of pain intensity, aiding in accurate pain management. It is widely used in healthcare settings, providing a standardized way to communicate and monitor pain levels. Visual analog scale (B) is subjective and less precise than numeric scales. Facial expression scale (C) may be influenced by cultural factors and is subjective. Observing for signs of depression (D) is important but not specific to assessing pain intensity.

Correct Answer: C

Rationale: The correct answer is C: Dizziness and shakiness. This indicates hypoglycemia, a potential side effect of insulin therapy. Dizziness and shakiness are classic signs of low blood sugar levels, which can be dangerous if left untreated. Headache and blurred vision (Option A) can occur with high blood sugar. Increased thirst and urination (Option B) are symptoms of hyperglycemia. Dry mouth and skin (Option D) are not immediate concerns related to insulin therapy.

Correct Answer: D

Rationale: The correct answer is D: To treat human responses. This goal aligns with the nursing profession's focus on addressing the holistic needs of individuals. Nurses aim to understand and manage patients' emotional, physical, and psychological responses to illness or treatment. By treating human responses, nurses can improve overall well-being. A: Providing cost-effective care is important but not a broad goal within nursing. It is a component of efficient healthcare delivery. B: Forming broad nursing diagnoses is a part of the nursing process, not a broad goal in itself. C: Promoting self-care is crucial in nursing practice, but it is more of a specific intervention rather than a broad goal encompassing the entire profession.