health assessment exam 1 test bank

health assessment exam 1 test bank Related

Review health assessment exam 1 test bank related questions and content

A patient drifts off to sleep when there is no stimulation. The nurse can arouse her easily by calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness would be:

  • A. Lethargic.
  • B. Obtunded.
  • C. Stuporous.
  • D. Semialert.
Correct Answer: A

Rationale: The correct answer is A: Lethargic. Lethargic is defined as a state of drowsiness or diminished alertness where the patient can be easily aroused by simple stimuli like calling their name, but they remain drowsy and may drift back to sleep. This patient's ability to be aroused by verbal stimuli and their drowsiness during conversation fits the description of lethargic.

Explanation for other choices:
B: Obtunded - Obtunded refers to a more severe level of decreased consciousness where the patient is difficult to fully arouse and may have limited interactions with the nurse.
C: Stuporous - Stuporous indicates an even deeper state of unconsciousness where the patient requires significant stimulation to be aroused and has minimal responsiveness.
D: Semialert - Semialert would describe a patient who is more responsive than lethargic, showing better awareness of their surroundings and able to maintain a conversation more effectively.

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A patient with diabetes is experiencing a hypoglycemic episode. Which of the following is the nurse's first priority in this situation?

  • A. Administering insulin.
  • B. Providing a source of fast-acting carbohydrate.
  • C. Checking the patient's blood glucose level.
  • D. Contacting the healthcare provider.
Correct Answer: B

Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In a hypoglycemic episode, the priority is to raise the blood sugar quickly to prevent further complications. Fast-acting carbohydrates such as glucose tablets or orange juice can rapidly increase blood sugar levels. Administering insulin (choice A) can further lower blood sugar, checking blood glucose levels (choice C) may delay treatment, and contacting the healthcare provider (choice D) is not necessary in the immediate management of hypoglycemia.

Expert nurses learn to attend to a pattern of assessment data and act without consciously labelling it. This is referred to as:

  • A. intuition.
  • B. the nursing process.
  • C. clinical knowledge.
  • D. diagnostic reasoning.
Correct Answer: A

Rationale: The correct answer is A: intuition. Expert nurses develop intuition through years of experience, allowing them to recognize patterns in assessment data and act quickly without conscious labeling. This intuitive response is based on a deep understanding of situations and is often more efficient than consciously going through the nursing process. Clinical knowledge (C) is important but refers to theoretical understanding. The nursing process (B) involves systematic steps in patient care, not the automatic response seen in intuition. Diagnostic reasoning (D) involves a more deliberate thought process in identifying and treating health issues.

Which of the following is the appropriate health promotion question to ask during a review of symptoms?

  • A. "Do you use sunscreen while outside?"
  • B. "I need to see if your skin is warm and dry."
  • C. "Have you experienced any dizziness or headaches?"
  • D. "When you cough, what colour is the sputum you bring up?"
Correct Answer: A

Rationale: The correct answer is A: "Do you use sunscreen while outside?" because it directly relates to health promotion by addressing preventive measures. Sunscreen helps prevent skin cancer and other skin conditions. Choice B is incorrect as it focuses on assessing skin condition rather than promoting health. Choice C is incorrect as it relates to symptoms rather than prevention. Choice D is incorrect as it is related to assessing a specific symptom rather than promoting overall health.

A nurse is providing education to a patient with hypertension. Which of the following statements by the patient indicates the need for further education?

  • A. I will limit my sodium intake.
  • B. I will monitor my blood pressure regularly.
  • C. I can stop taking my medication once my blood pressure is normal.
  • D. I will exercise regularly to improve my health.
Correct Answer: C

Rationale: The correct answer is C. This statement indicates a misunderstanding because stopping medication once blood pressure is normal can lead to a relapse of hypertension. Step 1: Medication management is crucial for long-term control of hypertension. Step 2: Stopping medication abruptly can cause blood pressure to rise again. Step 3: Regular monitoring, limiting sodium intake, and exercising are all important aspects of hypertension management. Summary: Choices A, B, and D demonstrate good understanding of hypertension management, while choice C shows a need for further education on the importance of continued medication use.

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

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

Rationale: The correct answer is A: Jaundice. In chronic liver disease, impaired liver function can result in the accumulation of bilirubin leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial in assessing the progression of liver disease.

B: Hypoglycemia is not a common complication of chronic liver disease. Liver plays a role in glycogen storage and glucose production, so hypoglycemia is less likely.

C: Hyperglycemia is more commonly associated with conditions like diabetes rather than chronic liver disease. The liver's role in glucose regulation may be impaired, but hyperglycemia is not a typical complication.

D: Anemia is not directly related to liver disease, although it may occur as a secondary complication due to factors like decreased production of certain blood components. Monitoring for anemia is important, but jaundice is a more specific complication of chronic liver disease.

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