A patient is post-operative following a total hip replacement. The nurse should prioritize which of the following to prevent complications?

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: B

Rationale: The correct answer is B, Health screenings such as mammograms, because secondary prevention focuses on early detection and treatment of diseases to prevent progression. Health screenings help identify conditions at early stages, allowing for timely intervention. Routine immunizations (A) are considered primary prevention as they prevent diseases from occurring. Smoking cessation programs (C) and health education on healthy eating (D) are examples of primary prevention, as they aim to prevent the development of diseases by promoting healthy behaviors.

Correct Answer: A

Rationale: 1. Increased sputum production is a sign of COPD exacerbation due to worsening inflammation and mucus production. 2. Decreased respiratory rate is not typical in COPD exacerbation as patients often experience increased respiratory effort. 3. Low blood pressure is not a common sign of COPD exacerbation and is more likely related to other conditions or medications. 4. High fever is not a typical sign of COPD exacerbation and could indicate an infection or other underlying issue.

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.

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: B

Rationale: The correct answer is B: Monitoring vital signs and oxygen saturation. This is the priority intervention because it allows the nurse to assess the patient's current cardiac status and detect any potential complications early. Monitoring vital signs provides crucial information on the patient's cardiovascular stability, while oxygen saturation levels indicate adequate tissue perfusion. Administering pain medication (A) can be important but not the priority. Deep breathing exercises (C) and providing nutritional education (D) are important but not as immediate as monitoring vital signs and oxygen saturation in a patient with a history of myocardial infarction.

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 the small, flat, brown macules described are consistent with lentigines (commonly known as age or liver spots), which are clusters of melanocytes that appear after prolonged sun exposure. This explanation directly addresses the patient's question about the cause of the spots and is supported by the clinical presentation. Choice A is incorrect because decreased hematocrit related to anemia would not cause these specific skin changes. Choice B is incorrect as destruction of melanin due to sun exposure would result in lighter spots, not dark brown macules. Choice D is incorrect because hyperpigmentation related to decreased perfusion and vasoconstriction would present differently and not primarily on sun-exposed areas like the arms and hands.

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.