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?

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.

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: 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.

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: C

Rationale: The correct answer is C: Dry mucous membranes. Dry mucous membranes are a common sign of dehydration as the body lacks adequate fluid. When a person is dehydrated, there is a decrease in saliva production, leading to dryness in the mouth and throat. This can be easily observed during a physical examination by looking at the patient's lips, tongue, and inside of the mouth. On the other hand, increased urine output (choice A) is a sign of adequate hydration, decreased heart rate (choice B) can be a normal response to dehydration but is not a consistent indicator, and increased blood pressure (choice D) is not typically associated with dehydration. Therefore, dry mucous membranes are the most reliable finding to suggest dehydration in a patient.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation. This is crucial post-total hip replacement to prevent complications such as blood clots, pneumonia, and muscle weakness. Early ambulation helps improve circulation, prevent stiffness, and promote faster recovery. Monitoring for infection (A) is important but not the top priority. Administering pain medications (C) and wound care (D) are essential but do not address the primary goal of preventing complications post-operatively.

Correct Answer: D

Rationale: The correct answer is D because it directly acknowledges the patient's distress and sets the stage for gathering essential information. By stating the need to ask questions about what happened, it shows empathy and readiness to provide help. Choice A is too formal and lacks empathy. Choice B shifts the focus away from the patient's distress. Choice C is similar to D but lacks the crucial element of acknowledging the patient's emotional state. Thus, D is the best choice for an opening statement in this scenario.

Correct Answer: C

Rationale: The correct answer is C because it indicates a misunderstanding about hypertension management. Patients should continue taking medication even if blood pressure is normal to prevent future complications. Monitoring blood pressure regularly (A) is important for tracking progress. Taking medication as prescribed (B) is crucial for controlling blood pressure. Reducing sodium intake (D) helps lower blood pressure. Choice C is incorrect as stopping medication prematurely can lead to uncontrolled hypertension.

Correct Answer: A

Rationale: The correct answer is A: He has a snake phobia. Phobias are irrational and persistent fears of specific objects or situations. In this case, the patient's fear of snakes is unreasonable and causes discomfort even when encountering pictures of snakes. This aligns with the characteristics of a phobia. Choice B is incorrect as hypochondriasis involves excessive worry about having a serious illness despite medical reassurance. Choice C is incorrect as obsessions are intrusive thoughts that cause anxiety, while the patient's fear of snakes is more of a specific fear rather than an obsession. Choice D is incorrect as delusions are fixed false beliefs, and the patient's fear of snakes is not based on a false belief but rather an irrational fear.