health assessment in nursing test bank

health assessment in nursing test bank Related

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A nurse is caring for a patient with chronic asthma. The nurse should monitor the patient for which of the following complications of asthma?

  • A. Hypoglycemia.
  • B. Oxygen toxicity.
  • C. Hyperkalemia.
  • D. Respiratory failure.
Correct Answer: D

Rationale: The correct answer is D: Respiratory failure. In chronic asthma, persistent inflammation and airway remodeling can lead to worsening lung function and respiratory distress, ultimately resulting in respiratory failure. Monitoring for signs of respiratory distress such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial.

A: Hypoglycemia is not a typical complication of asthma.
B: Oxygen toxicity is not a common complication in asthma management unless high concentrations of supplemental oxygen are administered for prolonged periods.
C: Hyperkalemia is not directly associated with asthma but may occur as a complication of certain asthma treatments or comorbid conditions.

Therefore, the priority complication to monitor in a patient with chronic asthma is respiratory failure due to the progressive nature of the disease and the potential for acute exacerbations.

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A 45-year-old woman suffered a head injury in a car accident. A few months after recovering from her injuries, she is unable to differentiate between hot and cold and is unsure of how to dress for the weather. This is an example of:

  • A. Mania.
  • B. Agnosia.
  • C. Dementia.
  • D. Amnestic disorder.
Correct Answer: B

Rationale: The correct answer is B: Agnosia. Agnosia is the inability to recognize or interpret sensory information, such as temperature or clothing. In this case, the woman's inability to differentiate between hot and cold and dress appropriately for the weather indicates a sensory processing issue, characteristic of agnosia.

A: Mania is a mood disorder characterized by extreme excitement and impulsivity, not related to sensory perception issues.
C: Dementia is a broad term for cognitive decline, which typically includes memory loss and impaired decision-making, but not necessarily sensory perception deficits.
D: Amnestic disorder refers to memory impairment, not the inability to interpret sensory information.

Which of the following responses might the nurse expect during the functional assessment of a patient whose leg is in a cast?

  • A. "I broke my right leg in a car accident 2 weeks ago."
  • B. "The pain is getting less, but I still need to take Tylenol."
  • C. "I check the colour of my toes every evening just like I was taught."
  • D. "I'm able to transfer myself from the wheelchair to the bed without help."
Correct Answer: D

Rationale: The correct answer is D because the nurse would expect the patient to demonstrate functional independence in activities like transferring from a wheelchair to the bed despite having a leg in a cast. This response indicates good mobility and strength, which are positive signs of recovery. Choices A, B, and C are incorrect as they do not directly address the functional assessment of the patient. Choice A provides historical information, choice B focuses on pain management, and choice C mentions a self-care routine that is not related to functional ability.

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

  • A. Hyperglycemia.
  • B. Hypoglycemia.
  • C. Dehydration.
  • D. Hypotension.
Correct Answer: A

Rationale: The correct answer is A: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels. Monitoring for hyperglycemia is crucial to prevent complications like diabetic ketoacidosis. Hypoglycemia (B) is low blood sugar, dehydration (C) is not directly related to diabetes unless it causes hyperosmolar hyperglycemic state, and hypotension (D) is low blood pressure, which is not a common complication of diabetes. Regular monitoring for hyperglycemia helps in preventing diabetic complications.

A nurse is teaching a patient with asthma about proper inhaler use. Which of the following statements by the patient indicates the need for further education?

  • A. I should hold my breath for 10 seconds after inhaling the medication.
  • B. I should use my inhaler before exercise to prevent symptoms.
  • C. I can use my inhaler every 30 minutes if I have trouble breathing.
  • D. I should rinse my mouth after using my inhaler to prevent thrush.
Correct Answer: C

Rationale: The correct answer is C because using the inhaler every 30 minutes for trouble breathing is not recommended. Overuse can lead to medication side effects and potential worsening of symptoms.
A: Holding breath after inhaling helps medication reach lungs.
B: Using inhaler before exercise can prevent exercise-induced symptoms.
D: Rinsing mouth prevents thrush, a common side effect of inhaled corticosteroids.

A 75-year-old woman is at the clinic for a preoperative interview. The nurse is aware that the interview with her may take longer than interviews with younger persons. What is the reason for this?

  • A. An older adult has a longer story to tell.
  • B. An older adult is usually lonely and likes to have someone to talk to.
  • C. Older adults lose much of their mental abilities and require more time to complete an interview.
  • D. As a person ages, he or she is unable to hear well, so interviewers usually need to frequently repeat what they say.
Correct Answer: A

Rationale: The correct answer is A because as people age, they accumulate more life experiences, medical history, and details to share. This can lead to longer conversations during interviews. Choice B is incorrect as not all older adults are lonely and seek conversation. Choice C is incorrect because aging does not necessarily equate to a loss of mental abilities. Choice D is incorrect as hearing loss is not a universal issue among older adults and does not significantly impact the length of interviews.

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