advanced health assessment test bank

advanced health assessment test bank Related

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

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

Rationale: The correct answer is D: Hyperglycemia. In diabetes, hyperglycemia occurs when blood sugar levels are too high. This can lead to various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. Monitoring for hyperglycemia is crucial to prevent these serious complications.

A: Hypoglycemia is low blood sugar and can also occur in diabetes, but it is not the primary complication to monitor for in this case.
B: Hyperkalemia is high potassium levels and is not a common complication of diabetes unless there are other underlying issues.
C: Hypotension is low blood pressure, which can be a complication of diabetes but is not as directly related to glucose management as hyperglycemia.

In summary, monitoring for hyperglycemia is essential in diabetes care to prevent serious complications associated with high blood sugar levels.

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Which of the following statements about nursing diagnoses is true? Nursing diagnoses:

  • A. evaluate the etiology of disease.
  • B. are a process based on medical diagnosis.
  • C. evaluate the response of the whole person to actual or potential health problems.
  • D. focus on the function and malfunction of a specific organ system in response to disease.
Correct Answer: C

Rationale: Rationale:
1. Nursing diagnoses evaluate the response of the whole person to health problems, not just specific organ systems.
2. They focus on the individual's physical, emotional, social, and spiritual well-being.
3. Nursing diagnoses are independent of medical diagnoses and consider the person holistically.
4. Option C aligns with the nursing process and the holistic approach of nursing care.

Summary:
Option A is incorrect as nursing diagnoses do not solely evaluate the etiology of disease. Option B is incorrect as nursing diagnoses are independent of medical diagnoses. Option D is incorrect as nursing diagnoses focus on the whole person, not just specific organ systems.

A nurse is teaching a patient about managing chronic pain. Which of the following strategies should the nurse emphasize?

  • A. Increasing activity to improve function.
  • B. Using medications only when absolutely necessary.
  • C. Implementing physical therapy and exercises.
  • D. Using complementary therapies such as meditation and relaxation.
Correct Answer: C

Rationale: The correct answer is C: Implementing physical therapy and exercises. This is crucial for managing chronic pain as it helps improve strength, flexibility, and overall function. Physical therapy can also address underlying issues contributing to pain. Choice A could worsen pain if not done appropriately. Choice B may be necessary but should not be the sole approach. Choice D can be beneficial but may not address the root cause of pain like physical therapy does.

The nurse is obtaining the health history of an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?

  • A. Obstetrical history
  • B. Childhood illnesses
  • C. General health for the past 20 years
  • D. Current health promotion activities
Correct Answer: D

Rationale: Rationale:
1. Current health promotion activities are important to assess the patient's preventive measures.
2. At 87 years old, focusing on current habits can help identify areas for improvement.
3. Obstetrical history is irrelevant as the patient is postmenopausal.
4. Childhood illnesses are less relevant compared to current health status.
5. General health for the past 20 years may not reflect current health behaviors.

Which of the following statements is an example of flight of ideas?

  • A. My stomach hurts. Hurts, spurts, burts.
  • B. Kiss, wood, reading, ducks, onto, maybe.
  • C. Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom.
  • D. I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.
Correct Answer: C

Rationale: The correct answer is C because it demonstrates a rapid succession of loosely associated thoughts, typical of flight of ideas. The statement transitions from discussing a pill to the color red, then red velvet, and finally to a baby's bottom. This rapid and disjointed flow of thoughts is characteristic of flight of ideas, a symptom commonly seen in manic episodes of bipolar disorder. Choices A, B, and D do not exhibit the same level of rapid and tangential thoughts as choice C, making them incorrect.

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

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

Rationale: The correct answer is B: Jaundice. In chronic liver disease, impaired liver function leads to the accumulation of bilirubin in the blood, causing jaundice. Jaundice is a common complication seen in patients with liver disease. Anemia (choice A) may occur in liver disease but is not as specific as jaundice. Hypertension (choice C) is not a direct complication of liver disease. Hypoglycemia (choice D) is more commonly associated with pancreatic disorders, not liver disease. Therefore, monitoring for jaundice is crucial in patients with chronic liver disease.

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