A nurse is caring for a patient with a history of hypertension. The nurse should educate the patient to monitor for which of the following complications?

Correct Answer: A

Rationale: The correct answer is A: Severe headaches and blurred vision. Hypertension can lead to complications such as hypertensive crisis, causing symptoms like severe headaches and blurred vision due to increased pressure in the blood vessels. This can indicate a serious health issue requiring immediate medical attention. Weight loss and dizziness (B), increased appetite and tremors (C), and nausea and vomiting (D) are not typically associated with hypertension complications. It's crucial for the nurse to educate the patient on recognizing these signs to prevent further health risks.

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: Ear. Examining the ear first is crucial in infants as it allows the nurse to assess for any signs of infection or abnormalities that could impact the infant's overall health. Ear infections are common in infants and can lead to serious complications if not detected early. By examining the ear first, the nurse can promptly address any issues and provide appropriate treatment. Summary of why other choices are incorrect: - B: Nose - While examining the nose is important, it is not the priority in infants as ear issues are more common and can have immediate implications on health. - C: Throat - Throat examination is important but typically follows ear examination in infants, as ear infections are more prevalent. - D: Abdomen - Abdominal examination is important for overall health assessment but is not the initial area to examine in infants as ear issues take precedence due to their frequency and potential impact.

Correct Answer: C

Rationale: The correct answer is C because the Montreal Cognitive Assessment (MoCA) is specifically designed to detect delirium and dementia and differentiate these conditions from psychiatric mental illness. It assesses various cognitive domains such as memory, attention, language, and visuospatial abilities. Scores below the normal range on the MoCA can indicate cognitive impairment related to delirium or dementia. Choice A is incorrect because a score below 30 on the MoCA does not necessarily indicate cognitive impairment; it depends on the individual's baseline and education level. Choice B is incorrect because the MoCA primarily focuses on cognitive function rather than mood and thought processes. Choice D is incorrect because while the MoCA can be used for initial evaluation of cognitive function, it is not sufficient for evaluating changes over time. Additional tools and assessments are needed for longitudinal monitoring of cognitive changes.

Correct Answer: C

Rationale: The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall. A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task. B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue. D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.

Correct Answer: A

Rationale: The correct answer is A: Palpation. Palpation involves using the hands to touch and feel the skin to assess its temperature accurately. This technique allows the nurse to detect variations in temperature more effectively compared to visual inspection (Choice C) or listening with a stethoscope (Choice B). Using a thermometer (Choice D) may also provide a precise measurement, but palpation allows for a more comprehensive assessment of skin temperature by considering factors such as localized warmth or coolness.

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.

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: 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.