advanced health assessment test bank

advanced health assessment test bank Related

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The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

  • A. Examine only the body areas related to the problem for which the patient is hospitalized, and then do a complete assessment after the problem has been resolved.
  • B. Perform a mini-database by examining the body areas directly related to the problem for which the patient is hospitalized.
  • C. Consider this a normal finding, and proceed with the abdominal assessment.
  • D. Examine the entire body to determine if the problem is linked to something else.
Correct Answer: A

Rationale: The correct answer is A because when a patient is experiencing significant shortness of breath, the nurse should initially focus on assessing the areas directly related to the presenting problem to address the immediate issue. This approach allows for prompt intervention and treatment of the patient's acute condition. Once the patient's respiratory distress is managed, the nurse can then proceed with a complete assessment to identify any underlying or additional health issues. This stepwise approach ensures that the patient's urgent needs are met first before conducting a comprehensive assessment.

Choices B, C, and D are incorrect because:

B: Performing a mini-database by only examining body areas directly related to the problem may not provide a comprehensive understanding of the patient's condition and could overlook other potential health issues.

C: Dismissing significant shortness of breath as a normal finding and proceeding with an abdominal assessment is inappropriate and could delay necessary interventions for the respiratory distress.

D: Examining the entire body to determine if the problem is linked to something else is inefficient and

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A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?

  • A. Pulmonary embolism.
  • B. Pneumothorax.
  • C. Hypercapnia.
  • D. Asthma attack.
Correct Answer: C

Rationale: The correct answer is C, hypercapnia. In COPD, impaired lung function leads to inadequate oxygen exchange, causing increased carbon dioxide levels in the blood (hypercapnia). This can result in respiratory acidosis and further exacerbate respiratory distress. Monitoring for hypercapnia is crucial in COPD management to prevent respiratory failure.

Incorrect choices:
A: Pulmonary embolism - While patients with COPD are at increased risk for blood clots, pulmonary embolism is not a direct complication of COPD.
B: Pneumothorax - Although individuals with COPD may develop pneumothorax due to weakened lung tissue, it is not a common complication.
D: Asthma attack - Asthma and COPD are distinct conditions with different pathophysiology. Asthma attacks are not a typical complication of COPD.

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.

A patient with heart failure is experiencing shortness of breath, fatigue, and swelling in the legs. The nurse should monitor for signs of which of the following complications?

  • A. Pulmonary embolism.
  • B. Renal failure.
  • C. Liver failure.
  • D. Worsening heart failure.
Correct Answer: D

Rationale: The correct answer is D: Worsening heart failure. Shortness of breath, fatigue, and leg swelling are common symptoms of heart failure. Monitoring for signs of worsening heart failure, such as increased dyspnea, weight gain, and decreased exercise tolerance, is crucial. Pulmonary embolism (A) presents with sudden chest pain and shortness of breath, not typically associated with chronic heart failure. Renal failure (B) may present with decreased urine output and electrolyte imbalances. Liver failure (C) may present with jaundice and changes in mental status. However, given the symptoms presented by the patient, monitoring for worsening heart failure is the most appropriate choice.

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.

The nurse is planning to assess new memory with a patient. The best way to do this would be to:

  • A. Administer the FACT test.
  • B. Ask him to describe his first job to you.
  • C. Give him the Four Unrelated Words Test.
  • D. Ask him to describe the last TV show he watched before coming to the clinic.
Correct Answer: C

Rationale: The correct answer is C: Give him the Four Unrelated Words Test. This is the best way to assess new memory because it is a standardized test specifically designed to evaluate a patient's ability to form new memories. The test involves presenting the patient with four unrelated words and then asking them to recall those words after a delay. This test is reliable, valid, and widely used in clinical settings to assess new memory formation.

Other choices are incorrect because:

A: Administering the FACT test is not the best way to assess new memory as it is not specifically designed for this purpose.

B: Asking the patient to describe his first job does not directly evaluate new memory formation and may not provide a standardized assessment.

D: Asking the patient to describe the last TV show he watched does not focus on new memory and is not a standardized way to assess memory function.

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