health assessment test bank jarvis

health assessment test bank jarvis Related

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A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to enjoy doing.' He also says that he is tired, sleeps poorly, and has no energy. To differentiate between dysthymic disorder and a major depressive disorder, which of the following questions should the nurse ask him?

  • A. Has there been any change in your weight?
  • B. Are you having any thoughts of suicide?
  • C. How long have you been feeling this way?
  • D. Are you having feelings of worthlessness?
Correct Answer: C

Rationale: Rationale: The correct answer is C: "How long have you been feeling this way?" This question is essential to differentiate between dysthymic disorder and major depressive disorder. In dysthymic disorder, symptoms persist for at least 2 years, whereas in major depressive disorder, symptoms typically last for at least 2 weeks. By asking how long the patient has been feeling this way, the nurse can determine the duration of the symptoms and make a more accurate diagnosis.

Summary of other choices:
A: "Has there been any change in your weight?" This question is more relevant to assessing changes in appetite, which can be a symptom of depression, but it does not differentiate between dysthymic and major depressive disorders.
B: "Are you having any thoughts of suicide?" While important to assess for safety, this question does not help differentiate between the two disorders.
D: "Are you having feelings of worthlessness?" This question is relevant to assessing symptoms of depression but does not

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How many teeth should an 18-month-old child have?

  • A. 6
  • B. 8
  • C. 12
  • D. 16
Correct Answer: C

Rationale: The correct answer is C: 12. At 18 months, a child should have 12 teeth, which include 8 incisors and 4 molars. This is because children typically start teething around 6 months, with the lower central incisors coming first. By 18 months, they should have all 8 incisors and usually the first set of molars. Options A, B, and D are incorrect because they do not align with the typical dental development timeline for children. Having only 6, 8, or 16 teeth at 18 months would indicate a delay or abnormality in dental growth.

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.

What is the most important intervention for a client with acute myocardial infarction (MI)?

  • A. Administer aspirin
  • B. Administer oxygen
  • C. Administer morphine
  • D. Administer nitroglycerin
Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.

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.

When interviewing a patient, it is important for the nurse to obtain some basic history. Which of the following statements should be explored more fully during an interview? The patient states that he:

  • A. Sleeps like a baby.
  • B. Has no health problems.
  • C. Never did too good in school.
  • D. Is currently not taking any medication.
Correct Answer: C

Rationale: The correct answer is C: "Never did too good in school." This statement should be explored further during an interview because it can provide insights into the patient's educational background, potential learning difficulties, or past experiences that may impact their health literacy or understanding of medical information. Understanding the patient's educational history can help the nurse tailor communication and education strategies effectively.

A: "Sleeps like a baby" is not as critical for further exploration as it pertains to the patient's sleep quality.
B: "Has no health problems" is important information but does not require immediate further exploration.
D: "Is currently not taking any medication" is important for medication reconciliation but does not warrant immediate further exploration in this context.

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