health assessment test bank jarvis

health assessment test bank jarvis Related

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A man has been admitted to the observation unit after having been treated for a large cut on his foreheaAs the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, "I quit smoking after my wife died 7 years ago." However, the nurse notices an open packet of cigarettes in his shirt pocket. If using confrontation as a response, the nurse could say:

  • A. Mr. K., you have said that you don't smoke, but I see that you have an open packet of cigarettes in your pocket.
  • B. Mr. K., come on, tell me how much you smoke.
  • C. Mr. K., I didn't realize your wife had dieIt must be difficult for you at this time. Please tell me more about that.
  • D. Mr. K., I know that you are lying.
Correct Answer: D

Rationale: The correct answer is D because using confrontation in this situation involves addressing the discrepancy between the patient's statement and observed behavior without being aggressive or judgmental. By stating, "Mr. K., I know that you are lying," the nurse directly addresses the inconsistency, encouraging honesty and open communication. This approach can help build trust and facilitate a more honest discussion about the patient's tobacco use.

Choice A is incorrect as it is too direct and may come across as accusatory. Choice B is also incorrect as it does not acknowledge the discrepancy and may not lead to a productive conversation. Choice C is incorrect as it avoids addressing the issue and focuses on the patient's personal situation instead of the behavior in question.

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A patient is admitted to the hospital with an acute myocardial infarction. The nurse should prioritize which of the following actions?

  • A. Administering pain medication
  • B. Performing a head-to-toe assessment
  • C. Establishing an intravenous line
  • D. Administering oxygen
Correct Answer: D

Rationale: Correct Answer: D - Administering oxygen

Rationale:
1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload.
2. Administering oxygen helps alleviate ischemia and prevents further damage.
3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being.

Summary of other choices:
A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction.
B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation.
C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.

What is the most important nursing intervention for a client with severe dehydration?

  • A. Administer IV fluids
  • B. Monitor vital signs
  • C. Provide oral rehydration
  • D. Administer oxygen
Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. This is the most important nursing intervention for a client with severe dehydration because IV fluids provide rapid rehydration and help restore electrolyte balance efficiently. Monitoring vital signs (choice B) is important but not as crucial as providing immediate fluid replacement. Providing oral rehydration (choice C) may not be effective for severe dehydration as the client may have difficulty absorbing fluids orally. Administering oxygen (choice D) is not directly related to treating dehydration, so it is not the most important intervention in this scenario.

What is the best intervention for a client who is vomiting after surgery?

  • A. Administer antiemetics
  • B. Place the client in a supine position
  • C. Encourage deep breathing
  • D. Administer morphine
Correct Answer: D

Rationale: The correct answer is D: Administer morphine. The rationale is that vomiting after surgery can be a side effect of pain medication such as morphine. By administering morphine, the pain is reduced, which can help alleviate the vomiting. This intervention targets the root cause of the vomiting.
Other choices are incorrect because:
A: Administering antiemetics may help with nausea but does not address the underlying cause of vomiting.
B: Placing the client in a supine position may worsen vomiting due to increased abdominal pressure.
C: Encouraging deep breathing may help with relaxation but does not directly address the vomiting caused by pain.

What is the most appropriate intervention for a client with suspected peritonitis?

  • A. Administer antibiotics
  • B. Administer IV fluids
  • C. Place the client in a supine position
  • D. Administer epinephrine
Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum typically caused by infection. Administering antibiotics is crucial to treat the underlying infection. IV fluids (B) may be necessary to maintain hydration, but antibiotics address the root cause. Placing the client in a supine position (C) is not a specific intervention for peritonitis. Administering epinephrine (D) is not indicated for peritonitis as it is not a treatment for infection.

How many teeth should an 18-month-old child have?

  • A. 6
  • B. 8
  • C. 12
  • D. 16
Correct Answer: C

Rationale: The correct answer is C: 12. At 18 months, a child should have 12 teeth, which include 8 incisors and 4 molars. This is because children typically start teething around 6 months, with the lower central incisors coming first. By 18 months, they should have all 8 incisors and usually the first set of molars. Options A, B, and D are incorrect because they do not align with the typical dental development timeline for children. Having only 6, 8, or 16 teeth at 18 months would indicate a delay or abnormality in dental growth.

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