health assessment test bank

health assessment test bank Related

Review health assessment test bank related questions and content

Which nursing intervention should be prioritized for a client with congestive heart failure (CHF)?

  • A. Administer diuretics
  • B. Limit fluid intake
  • C. Promote activity
  • D. Maintain fluid balance
Correct Answer: C

Rationale: Rationale for Correct Answer (C): Promoting activity is the most prioritized nursing intervention for a client with CHF. Activity helps improve cardiac function, decreases fluid accumulation, and enhances overall cardiovascular health. It also prevents complications like muscle weakness and deconditioning. It is crucial in managing CHF symptoms and improving the client's quality of life.

Summary of Incorrect Choices:
A: Administering diuretics helps in reducing fluid overload but does not address the underlying issue of improving cardiac function through physical activity.
B: Limiting fluid intake is important, but promoting activity takes precedence as it directly impacts cardiac function and fluid accumulation.
D: Maintaining fluid balance is necessary but is a broad concept that includes various interventions, with promoting activity being more focused and critical in CHF management.

You may also like to solve these questions

What is the most important intervention for a client with a wound infection?

  • A. Administer antibiotics
  • B. Apply a cold compress
  • C. Apply heat to the wound
  • D. Administer IV fluids
Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating wound infections as they target and eliminate the infection-causing bacteria, preventing the infection from spreading and promoting healing. Applying a cold compress (choice B) or heat (choice C) may provide temporary relief but do not address the underlying infection. Administering IV fluids (choice D) may be necessary for hydration, but it does not directly treat the infection. Antibiotics directly target the infection, making it the most important intervention for a client with a wound infection.

Which quadrant of the abdomen is tender in suspected appendicitis?

  • A. upper right
  • B. upper left
  • C. lower right
  • D. lower left
Correct Answer: C

Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.

What assessment framework provides additional modesty for clients, such as teenage girls?

  • A. Body systems
  • B. Functional
  • C. Focused
  • D. Head to toe
Correct Answer: D

Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.

A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:

  • A. objective.
  • B. reflective.
  • C. subjective.
  • D. introspective.
Correct Answer: C

Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice B) and introspective (choice D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.

A patient keeps saying, "I feel hot. Hot, cot, rot, tot, got. I'm a spot.' This is an illustration of:

  • A. Blocking.
  • B. Clanging.
  • C. Echolalia.
  • D. Neologism.
Correct Answer: B

Rationale: The correct answer is B: Clanging. Clanging refers to the phenomenon where words are chosen based on sound rather than meaning. In this case, the patient's speech demonstrates a pattern of words that rhyme or have similar sounds, despite lacking coherence or logical connection. This behavior is commonly seen in individuals with conditions like schizophrenia.

Incorrect choices:
A: Blocking - Blocking refers to sudden interruption or cessation of speech. This does not apply to the scenario described.
C: Echolalia - Echolalia involves repetition of words or phrases spoken by others, not self-generated word patterns like in the scenario.
D: Neologism - Neologism refers to the creation of new words or phrases with unique meanings, which is not reflected in the patient's speech pattern.

Copyright © 2025 Nokea. All rights reserved.