health assessment test bank jarvis

health assessment test bank jarvis Related

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A patient of African descent is in the critical care unit to be monitored for shock after an accident. What skin characteristics would the nurse expect to find in this patient?

  • A. Ruddy blue
  • B. Generalized pallor
  • C. Ashen, grey, or dull
  • D. Patchy areas of pallor
Correct Answer: C

Rationale: The correct answer is C: Ashen, grey, or dull. In patients of African descent, skin characteristics may appear ashen, grey, or dull when experiencing shock due to reduced blood flow and oxygen delivery. This is because the skin may appear pale or lacking in color due to decreased perfusion.

The other choices are incorrect because:
A: Ruddy blue - Ruddy blue skin color is not typically associated with shock in patients of African descent.
B: Generalized pallor - Generalized pallor refers to an overall paleness of the skin, which is not commonly seen in patients of African descent during shock.
D: Patchy areas of pallor - Patchy areas of pallor suggest uneven skin color changes, which are not typically characteristic of shock in patients of African descent.

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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.

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

  • A. Weight loss and increased appetite.
  • B. Increased urine output and dehydration.
  • C. Swelling in the legs and shortness of breath.
  • D. Nausea and vomiting.
Correct Answer: C

Rationale: The correct answer is C: Swelling in the legs and shortness of breath. In heart failure, the heart is unable to pump effectively, leading to fluid accumulation in the body. Swelling in the legs (edema) is a classic sign of fluid overload as the fluid pools in the lower extremities. Shortness of breath occurs due to fluid accumulating in the lungs, causing difficulty in breathing. Weight loss and increased appetite (A) are not typical signs of fluid overload. Increased urine output and dehydration (B) are more indicative of fluid deficit. Nausea and vomiting (D) can occur in various conditions but are not specific to fluid overload in heart failure.

Which of the following is the most appropriate response for a nurse caring for a client who is experiencing a stroke?

  • A. Perform a neurological assessment
  • B. Initiate a stroke protocol
  • C. Position the client on their side
  • D. Start a CT scan
Correct Answer: B

Rationale: The correct answer is B: Initiate a stroke protocol. This is the most appropriate response because time is critical in treating a stroke. By initiating a stroke protocol, the nurse ensures that the client receives prompt and appropriate care, including timely evaluation, imaging studies, and potential interventions such as administering clot-busting medication. Performing a neurological assessment (A) is important but may delay crucial interventions. Positioning the client on their side (C) is essential for airway protection but should not be the initial priority. Starting a CT scan (D) is important for diagnosis but should not delay the initiation of the stroke protocol, which includes obtaining imaging studies.

What is the first action the nurse should take when a client presents with signs of respiratory distress?

  • A. Open the airway
  • B. Administer oxygen
  • C. Administer medication
  • D. Administer pain relief
Correct Answer: A

Rationale: The correct answer is A: Open the airway. This is the first action because in respiratory distress, ensuring a clear airway is crucial for adequate oxygenation. Opening the airway helps facilitate breathing and prevents further complications. Administering oxygen (choice B) can be done after ensuring the airway is clear. Administering medication (choice C) and pain relief (choice D) are not the initial priority in managing respiratory distress.

Which factors increase the risk of sexually transmitted diseases (STDs)?

  • A. alcohol use
  • B. certain types of sexual practices
  • C. oral contraception use
  • D. all of the above
Correct Answer: D

Rationale: The correct answer is D: all of the above. Alcohol use can impair judgment leading to risky sexual behaviors. Certain sexual practices like unprotected sex or having multiple partners increase STD risk. Oral contraception does not protect against STDs. Therefore, all factors (A, B, C) collectively increase the risk of STDs.

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