jarvis physical examination and health assessment 9th edition test bank

Correct Answer: D

Rationale: The correct answer is D because it directly addresses the inappropriate behavior, sets a boundary, and communicates the nurse's discomfort in a professional manner. By stating that the comment makes them uncomfortable and asking the patient to refrain from such behavior, the nurse asserts their professionalism while maintaining respect for both parties. Choice A is too abrupt and may escalate the situation. Choice B dismisses the behavior, which is inappropriate. Choice C could be perceived as confrontational and potentially lead to a defensive response from the patient.

Correct Answer: A

Rationale: The correct answer is A, shortness of breath and weight gain, because fluid overload in patients with chronic kidney disease can lead to pulmonary edema and weight gain due to retained fluid. Shortness of breath occurs as the excess fluid accumulates in the lungs. Increased urine output and fatigue (B) are more indicative of dehydration. Dizziness and hypotension (C) are symptoms of hypovolemia, not fluid overload. Nausea and vomiting (D) are nonspecific symptoms and not typically associated with fluid overload.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation to prevent complications. Early ambulation after abdominal surgery helps prevent postoperative complications like deep vein thrombosis and pneumonia. It promotes circulation, aids in bowel function, and reduces the risk of atelectasis. Encouraging the patient to move also helps with pain management and overall recovery. Choice A: Administering antiemetics as needed. While addressing nausea and vomiting is important, it is not the top priority in this case. Choice C: Providing wound care and dressing changes. Wound care is crucial, but ensuring early ambulation takes precedence to prevent complications. Choice D: Monitoring for signs of infection. While monitoring for infection is essential, promoting early ambulation is a proactive measure to prevent various complications and enhance recovery.

Correct Answer: C

Rationale: The correct answer is C: Tremors and dizziness. Hypoglycemia is characterized by low blood sugar levels. Tremors and dizziness are common symptoms due to the brain not receiving enough glucose for energy. Tachycardia and nausea (choice A) are more indicative of hyperglycemia. Polyuria and polydipsia (choice B) are classic symptoms of hyperglycemia in diabetes. Weight loss and fatigue (choice D) are not specific symptoms of hypoglycemia.

Correct Answer: C

Rationale: The correct answer is C because a risk diagnosis involves identifying potential problems that an individual may develop in the future. This type of diagnosis focuses on preemptive measures to prevent or minimize the risk of these potential issues occurring. This is different from options A, B, and D, which do not pertain to future potential problems but rather current levels of wellness, past problems and goals, and strengths respectively. Therefore, option C best aligns with the concept of risk diagnosis in nursing classification.