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?

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.

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.

Correct Answer: A

Rationale: The correct answer is A because shortness of breath with minimal exertion indicates possible respiratory distress, which can be a sign of significant lung damage from smoking. This symptom suggests a decreased ability to exchange oxygen and carbon dioxide efficiently, potentially leading to serious health complications. Choice B is incorrect because an occasional cough with mucus production is common in smokers and may not be as alarming as shortness of breath. Choice C is incorrect as slight wheezing after physical activity could be due to exercise-induced asthma rather than solely smoking-related issues. Choice D is incorrect because even though the patient may not be experiencing symptoms related to smoking currently, it does not rule out potential underlying lung damage or future health risks associated with smoking.

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.

Correct Answer: A

Rationale: The correct answer is A: Jaundice. In chronic liver disease, impaired liver function can result in the accumulation of bilirubin leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial in assessing the progression of liver disease. B: Hypoglycemia is not a common complication of chronic liver disease. Liver plays a role in glycogen storage and glucose production, so hypoglycemia is less likely. C: Hyperglycemia is more commonly associated with conditions like diabetes rather than chronic liver disease. The liver's role in glucose regulation may be impaired, but hyperglycemia is not a typical complication. D: Anemia is not directly related to liver disease, although it may occur as a secondary complication due to factors like decreased production of certain blood components. Monitoring for anemia is important, but jaundice is a more specific complication of chronic liver disease.

Correct Answer: A

Rationale: The correct answer is A: intuition. Expert nurses develop intuition through years of experience, allowing them to recognize patterns in assessment data and act quickly without conscious labeling. This intuitive response is based on a deep understanding of situations and is often more efficient than consciously going through the nursing process. Clinical knowledge (C) is important but refers to theoretical understanding. The nursing process (B) involves systematic steps in patient care, not the automatic response seen in intuition. Diagnostic reasoning (D) involves a more deliberate thought process in identifying and treating health issues.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Post-operative hip replacement patients are at high risk for DVT due to immobility and surgical trauma. The nurse should monitor for signs such as swelling, redness, and pain in the affected leg. DVT can lead to serious complications like pulmonary embolism if not detected early. Choices A, C, and D are incorrect because while pneumonia, wound infection, and hypoglycemia are also potential post-operative complications, they are not as directly associated with hip replacement surgery as DVT.

Correct Answer: D

Rationale: The correct answer is D: Subjective data. During the interview portion of data collection, subjective data is obtained as it involves personal opinions, feelings, and experiences shared by the interviewee. This data is based on individual perspectives and cannot be measured objectively. Physical data (A) refers to tangible measurements, historical data (B) relates to past events or records, and objective data (C) is based on observable and measurable facts. In contrast, subjective data (D) captures the interviewee's viewpoints and interpretations, making it the most appropriate choice for the given scenario.

Correct Answer: C

Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.