health assessment test bank jarvis

health assessment test bank jarvis Related

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A nurse is caring for a patient with a history of heart failure. The nurse should monitor for signs of which of the following complications?

  • A. Hypoglycemia.
  • B. Pulmonary edema.
  • C. Anemia.
  • D. Hypertension.
Correct Answer: B

Rationale: The correct answer is B: Pulmonary edema. In heart failure, the heart is unable to pump effectively, leading to fluid buildup in the lungs causing pulmonary edema. This can result in symptoms such as shortness of breath, coughing, and wheezing. Monitoring for pulmonary edema is crucial in heart failure management to prevent respiratory distress and worsening heart function.

Rationale:
A: Hypoglycemia - While patients with heart failure may be at risk for metabolic abnormalities, hypoglycemia is not a common complication directly related to heart failure.
C: Anemia - Anemia can occur in heart failure due to reduced oxygen-carrying capacity of the blood, but it is not a direct complication that requires immediate monitoring like pulmonary edema.
D: Hypertension - Heart failure is characterized by a reduced ability of the heart to pump blood effectively, leading to decreased cardiac output. Therefore, hypertension is not typically a complication seen in heart failure patients.

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What is the primary concern for a nurse caring for a client who is post-operative and experiencing confusion?

  • A. Notify the healthcare provider
  • B. Reorient the client
  • C. Increase circulation
  • D. Assess the level of pain
Correct Answer: B

Rationale: The correct answer is B: Reorient the client. Reorientation helps the confused client regain awareness of their surroundings, time, and situation post-operatively. It can improve their cognition and reduce anxiety. Notifying the healthcare provider (A) may be necessary but not the primary concern. Increasing circulation (C) is important but not the first step for a confused post-op client. Assessing pain (D) is important but addressing confusion takes precedence.

A nurse is providing education to a patient with hypertension. Which of the following lifestyle changes should the nurse prioritize?

  • A. Increasing physical activity and reducing salt intake.
  • B. Increasing alcohol consumption.
  • C. Decreasing physical activity.
  • D. Increasing sodium intake.
Correct Answer: A

Rationale: The correct answer is A: Increasing physical activity and reducing salt intake. Firstly, increasing physical activity helps lower blood pressure by improving heart health and circulation. Secondly, reducing salt intake helps decrease fluid retention and lower blood pressure. The other choices are incorrect because B: Increasing alcohol consumption can raise blood pressure, C: Decreasing physical activity is counterproductive, and D: Increasing sodium intake can lead to higher blood pressure due to fluid retention. Prioritizing physical activity and reducing salt intake are evidence-based lifestyle changes to manage hypertension effectively.

Which of the following statements accurately describes the concept of culturally competent care?

  • A. The health care provider is able to understand and speak the patient's mother tongue.
  • B. The health care provider possesses a basic knowledge of the patient's cultural background.
  • C. The health care provider has knowledge of the significance of social, economic, and cultural contexts.
  • D. The health care provider applies knowledge, skills, attitudes, and personal attributes to maximize respect and care.
Correct Answer: D

Rationale: Step 1: Culturally competent care involves applying knowledge, skills, attitudes, and personal attributes to provide respectful and effective care.
Step 2: Understanding and speaking the patient's mother tongue (Option A) is important but not sufficient for culturally competent care.
Step 3: Possessing basic knowledge of the patient's cultural background (Option B) is helpful, but not comprehensive enough to ensure culturally competent care.
Step 4: Having knowledge of the significance of social, economic, and cultural contexts (Option C) is crucial but does not encompass the full scope of culturally competent care.
Step 5: The correct answer, D, encompasses the holistic approach needed for culturally competent care by emphasizing the application of knowledge, skills, attitudes, and personal attributes to maximize respect and care.

A nurse is caring for a patient with diabetes who is newly diagnosed with diabetic nephropathy. The nurse should prioritize which of the following assessments?

  • A. Kidney function tests.
  • B. Blood pressure measurement.
  • C. Blood glucose levels.
  • D. Urine output monitoring.
Correct Answer: A

Rationale: The correct answer is A: Kidney function tests. In diabetic nephropathy, the kidneys are affected, leading to impaired kidney function. Monitoring kidney function tests such as serum creatinine and glomerular filtration rate is crucial to assess the progression of the disease and guide treatment. Blood pressure measurement (B) is important in managing diabetic nephropathy but does not directly assess kidney function. Blood glucose levels (C) are essential in managing diabetes overall but do not specifically address nephropathy. Urine output monitoring (D) is important for assessing kidney function but does not provide as comprehensive information as kidney function tests.

What is the most important intervention for a client experiencing an allergic reaction?

  • A. Administer epinephrine
  • B. Administer antihistamines
  • C. Administer corticosteroids
  • D. Administer beta-blockers
Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis, a severe allergic reaction. It works by constricting blood vessels, increasing heart rate, and opening airways, which can reverse the life-threatening effects of an allergic reaction. Antihistamines (B) may help with mild symptoms but are not sufficient for severe reactions. Corticosteroids (C) are used to reduce inflammation but work too slowly for immediate relief. Beta-blockers (D) can worsen allergic reactions by blocking the effects of epinephrine.

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