health assessment in nursing test bank

health assessment in nursing test bank Related

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The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the:

  • A. nursing diagnosis.
  • B. medical diagnosis.
  • C. admission diagnosis.
  • D. collaborative diagnosis.
Correct Answer: A

Rationale: Step-by-step rationale:
1. Nursing interventions are based on nursing diagnosis, which identifies patient's unique health needs.
2. Nursing diagnosis focuses on patient's response to health problems, not just medical conditions.
3. It guides nurses in planning individualized care to meet patient's specific needs.
4. Medical diagnosis (B) focuses on disease pathology, not holistic patient care.
5. Admission diagnosis (C) is a temporary identification of patient's primary reason for admission.
6. Collaborative diagnosis (D) involves joint identification of interprofessional health problems, not specific to nursing care.

Summary:
The correct answer is A because nursing interventions are tailored based on nursing diagnosis, which considers patient's responses to health issues. Medical diagnosis, admission diagnosis, and collaborative diagnosis do not provide the same level of individualized and holistic care planning as nursing diagnosis.

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

  • A. Administering supplemental oxygen as needed.
  • B. Encouraging regular physical activity.
  • C. Administering antibiotics regularly.
  • D. Providing increased fluid intake.
Correct Answer: A

Rationale: The correct answer is A: Administering supplemental oxygen as needed. This is the priority intervention for a patient with COPD because it helps improve oxygenation and relieve respiratory distress, which is the main concern in COPD. Supplemental oxygen also helps reduce the workload on the heart and other organs. Encouraging physical activity (B) is important for overall health but may not be the priority in acute exacerbations. Administering antibiotics regularly (C) is not necessary unless there is a documented infection. Providing increased fluid intake (D) is important for maintaining hydration but is not the priority intervention in this case.

A nurse is teaching a patient with diabetes about managing their condition. Which of the following statements by the patient indicates the need for further education?

  • A. I will monitor my blood glucose regularly.
  • B. I will exercise regularly to help manage my condition.
  • C. I will stop taking my insulin when my blood glucose is normal.
  • D. I will eat a balanced diet to manage my blood glucose.
Correct Answer: C

Rationale: The correct answer is C because stopping insulin when blood glucose is normal is incorrect. Insulin is necessary for managing diabetes even when blood glucose levels are normal to prevent fluctuations. Monitoring blood glucose (A), exercising (B), and eating a balanced diet (D) are all important components of diabetes management. Stopping insulin abruptly can lead to hyperglycemia and potential complications.

A nurse is teaching a patient with diabetes about self-management. Which of the following statements by the patient indicates the need for further education?

  • A. I will check my blood sugar regularly.
  • B. I will take my insulin only when my blood sugar is high.
  • C. I will eat a balanced diet and exercise regularly.
  • D. I will report any signs of infection to my healthcare provider.
Correct Answer: B

Rationale: Correct Answer: B

Rationale:
1. Taking insulin only when blood sugar is high can lead to uncontrolled levels.
2. Regular insulin dosing is essential for diabetes management.
3. Monitoring blood sugar regularly helps in adjusting insulin doses.
4. Eating a balanced diet and exercising are key components of diabetes management.
5. Reporting signs of infection is crucial due to diabetes-related complications.

A nurse preparing to conduct a prenatal class is aware that which of the following groups is at highest risk for infant mortality?

  • A. European Canadians
  • B. Asian Canadians
  • C. African Canadians
  • D. First Nations people
Correct Answer: D

Rationale: The correct answer is D: First Nations people. First Nations people in Canada have historically faced systemic barriers to healthcare, leading to higher rates of infant mortality compared to other groups. This includes socio-economic factors, access to quality healthcare, and cultural differences impacting healthcare practices. European Canadians, Asian Canadians, and African Canadians do not face the same level of disparities and risk factors contributing to infant mortality rates as First Nations people. It is essential for healthcare providers to understand these disparities to address the health needs of First Nations communities effectively.

A nurse is caring for a patient with hypertension. Which of the following lifestyle changes would the nurse prioritize to help manage the patient's blood pressure?

  • A. Increasing sodium intake.
  • B. Losing weight and increasing physical activity.
  • C. Consuming more processed foods.
  • D. Limiting fluid intake.
Correct Answer: B

Rationale: The correct answer is B. Losing weight and increasing physical activity help manage blood pressure by reducing excess body weight, improving heart function, and enhancing blood flow. This leads to lower blood pressure levels.
A: Increasing sodium intake would worsen hypertension by promoting fluid retention and raising blood pressure.
C: Consuming more processed foods often includes high levels of sodium, unhealthy fats, and additives that can negatively impact blood pressure.
D: Limiting fluid intake is not a primary lifestyle change for managing hypertension; adequate fluid intake is important for overall health and blood pressure regulation.

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