advanced health assessment test bank

advanced health assessment test bank Related

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The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which of the following would be the next appropriate action?

  • A. Establishing priorities
  • B. Identifying expected outcomes
  • C. Evaluating the individual's condition and comparing actual outcomes with expected outcomes
  • D. Interpreting data, identifying clusters of cues, and making inferences
Correct Answer: C

Rationale: The next appropriate action is to evaluate the individual's condition and compare actual outcomes with expected outcomes (Choice C). This step is crucial in determining the effectiveness of the implemented interventions in addressing the nursing diagnosis of acute pain. By evaluating the individual's condition, the nurse can assess whether the interventions have been successful in alleviating the pain. Comparing actual outcomes with expected outcomes helps in identifying any discrepancies and adjusting the plan of care accordingly to ensure optimal patient outcomes.

Establishing priorities (Choice A) is important but would come before implementing interventions. Identifying expected outcomes (Choice B) is necessary before implementing interventions but does not directly address the need for evaluation. Interpreting data and making inferences (Choice D) is part of the assessment phase and not the next appropriate action after implementing interventions.

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

  • A. Increased urine output and weight loss.
  • B. Swelling in the legs and shortness of breath.
  • C. Decreased blood pressure and dizziness.
  • D. Fatigue and constipation.
Correct Answer: B

Rationale: The correct answer is B: Swelling in the legs and shortness of breath. In heart failure, fluid can build up in the body causing swelling, particularly in the legs. Shortness of breath is a common symptom due to fluid accumulation in the lungs. Increased urine output and weight loss (A) are not indicative of worsening heart failure as they suggest fluid loss. Decreased blood pressure and dizziness (C) can be seen in other conditions like dehydration. Fatigue and constipation (D) are not specific signs of heart failure worsening.

When examining a patient, the nurse can assess mental health by:

  • A. Examining the patient's electroencephalogram.
  • B. Observing the patient as he or she performs an IQ test.
  • C. Observing the patient and inferring health or dysfunction.
  • D. Examining the patient's response to a specific set of questions.
Correct Answer: C

Rationale: The correct answer is C because observing the patient and inferring health or dysfunction allows the nurse to assess mental health holistically. This method considers various factors such as behavior, emotions, communication, and overall functioning. It provides a comprehensive view of the patient's mental well-being.

A: Examining the patient's electroencephalogram is more related to brain activity rather than mental health assessment.
B: Observing the patient as he or she performs an IQ test is limited to cognitive abilities and does not capture the full spectrum of mental health.
D: Examining the patient's response to a specific set of questions may not provide a complete picture of mental health as it focuses on specific aspects rather than overall assessment.

A man has come in to the clinic because he is afraid he might have skin cancer. During the skin assessment, the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on' on his skin. Which of the following is the best prediction?

  • A. He probably has senile lentigines, which do not become cancerous.
  • B. He probably has actinic keratoses, precursors to basal cell carcinoma.
  • C. He probably has acrochordons, precursors to squamous cell carcinoma.
  • D. He probably has seborrheic keratosis, which do not become cancerous.
Correct Answer: D

Rationale: The correct answer is D: He probably has seborrheic keratosis, which do not become cancerous. Seborrheic keratosis typically appear as greasy, dark, and "stuck on" pigmented growths on the skin, commonly seen in older adults. They are benign and do not progress to skin cancer. This conclusion is based on the characteristics of seborrheic keratosis and the fact that they are not associated with malignancy.

Choice A (senile lentigines) is incorrect because although they are also common in older adults, they are flat and dark spots rather than raised growths. Choice B (actinic keratoses) is incorrect as they are precancerous lesions related to sun exposure, leading to a risk of developing squamous cell carcinoma, not basal cell carcinoma. Choice C (acrochordons) are skin tags and not precursors to squamous cell carcinoma.

A nurse is teaching a patient with diabetes about insulin administration. Which of the following statements by the patient indicates proper understanding?

  • A. I will inject insulin into my arm to ensure faster absorption.
  • B. I will rotate injection sites to avoid tissue damage.
  • C. I should inject insulin only when my blood glucose is elevated.
  • D. I should inject insulin into the same spot every time to ensure consistency.
Correct Answer: B

Rationale: The correct answer is B: I will rotate injection sites to avoid tissue damage. This statement indicates proper understanding because rotating injection sites helps prevent tissue damage and ensures consistent absorption. Injecting into the same spot every time can lead to lipohypertrophy. Injecting insulin only when blood glucose is elevated is incorrect as insulin is needed regularly. Injecting into the arm for faster absorption is also incorrect, as it can lead to unpredictable absorption rates. Rotation of sites is crucial for optimal insulin absorption and to prevent complications.

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.

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