The nurse is preparing to examine an infant. Which of the following actions is the most appropriate to perform first?

Correct Answer: C

Rationale: The correct answer is C: Begin with the head. This is the most appropriate action as starting with the head allows the nurse to establish rapport with the infant and assess their level of alertness before progressing further. By starting at the head, the nurse can also observe the infant's facial expressions and interactions with the caregiver, providing valuable information about the infant's overall well-being. Assessing reflexes first (Choice A) may startle the infant, asking the parent to undress the child (Choice B) can be done after the initial assessment, and beginning with the legs (Choice D) does not prioritize the critical areas of observation such as the head and face.

Correct Answer: B

Rationale: The correct answer is B: Increase potassium intake. Potassium helps to lower blood pressure by counteracting the effects of sodium. This dietary change is crucial for managing hypertension. Increasing sodium intake (choice A) is incorrect as it can lead to increased blood pressure. Increasing fiber intake (choice C) is beneficial for overall health but not specifically for hypertension. Increasing alcohol intake (choice D) is harmful and can worsen hypertension. Prioritizing increasing potassium intake is essential for effectively managing hypertension.

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: Step 1: Hypertension is often worsened by high sodium intake. Step 2: Decreasing sodium intake helps lower blood pressure. Step 3: This dietary change aligns with hypertension management. Step 4: Increasing processed foods (A), saturated fats (D), or potassium intake (B) do not directly address the issue of high sodium intake and may even exacerbate hypertension.

Correct Answer: D

Rationale: Step 1: Establish rapport by showing interest in the patient's well-being. Step 2: Emphasize continuity of care by referencing the previous visit. Step 3: Encourage open communication about any changes or concerns. Step 4: Initiate discussion on the patient's health status since the last visit. Summary: A - Too broad and not focused on the patient's own health. B - Assumes the patient has a specific reason for the visit. C - Assumes the patient has hypertension and may not be relevant. D - Encourages discussion on the patient's health status and continuity of care.

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.

Correct Answer: D

Rationale: The correct answer is D: Both B and C. After knee replacement surgery, patients are at risk for developing DVT and pulmonary embolism due to immobility and surgery-related factors. DVT occurs when a blood clot forms in a deep vein, usually in the legs, which can lead to a pulmonary embolism if the clot travels to the lungs. Monitoring for both complications is crucial to prevent serious consequences. Option A, hyperglycemia, is not a common complication following knee replacement surgery and is not directly related to immobility or surgery. Option B, DVT, is correct but does not encompass the risk of pulmonary embolism. Option C, pulmonary embolism, is correct but does not cover the initial risk of DVT formation. Therefore, monitoring for both DVT and pulmonary embolism is essential in post-operative knee replacement patients.

Correct Answer: C

Rationale: The correct answer is C. Drinking caffeinated beverages can potentially increase blood pressure due to their stimulant effect. Limiting caffeine intake is recommended for patients with hypertension. Statement A is correct as reducing sodium and increasing potassium intake can help lower blood pressure. Statement B is correct as processed foods and fast food are typically high in sodium and unhealthy fats, which can worsen hypertension. Statement D is correct as fruits, vegetables, and whole grains are part of a heart-healthy diet for managing hypertension.

Correct Answer: B

Rationale: The correct answer is B because encouraging early ambulation is a priority post-operative intervention for a patient following a hip replacement. Early ambulation helps prevent complications such as blood clots, muscle weakness, and pneumonia. It also promotes circulation and aids in the patient's recovery. Administering pain medications (A) is important but not the top priority. Monitoring for signs of infection (C) is crucial, but ambulation takes precedence. Providing wound care (D) is essential but can be done after ensuring the patient's mobility.