Which of the following is an example of a secondary prevention activity?

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: B

Rationale: The correct answer is B: Clustering-related cues. This critical thinking skill helps the nurse recognize relationships among data by grouping related information together. This aids in identifying patterns, connections, and trends within the data, leading to a better understanding of the situation. Validation (A) involves confirming the accuracy of data, not necessarily recognizing relationships. Identifying gaps in data (C) focuses on missing information rather than relationships among existing data. Distinguishing relevant from irrelevant (D) is important but does not directly address recognizing relationships among data. In summary, clustering-related cues (B) is the most relevant skill for recognizing relationships among data in critical thinking.

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: 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: 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: 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: 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: 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.