health assessment in nursing test bank

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation. This is because early ambulation is crucial in preventing complications such as blood clots and muscle atrophy post hip replacement surgery. It helps improve circulation, prevent joint stiffness, and promote healing. Administering pain medication regularly (A) is important but not the top priority. Providing wound care and dressing changes (C) and monitoring for signs of infection (D) are also important but secondary to early ambulation in preventing complications and promoting recovery.

Correct Answer: D

Rationale: The correct answer is D: Inappropriate affect. Inappropriate affect refers to emotions that are not congruent with the situation. In this case, the patient's laughing while describing a horrifying image indicates a disconnect between his emotions and the context. This behavior is commonly seen in schizophrenia, where there is a lack of appropriate emotional response. A: Confusion does not accurately describe the patient's behavior, as he is able to describe the picture and his emotional response to it. B: Ambivalence refers to conflicting emotions or attitudes, which is not evident in the patient's behavior. C: Depersonalization involves feeling detached from oneself or reality, which is not evident in the patient's behavior. In summary, the patient's inappropriate laughter in response to a horrifying image is indicative of inappropriate affect, a common feature of schizophrenia.

Correct Answer: D

Rationale: The correct answer is D: Papule. A papule is a solid, elevated lesion that is less than 1 cm in diameter. It is circumscribed, meaning it has well-defined borders. Papules are often associated with skin conditions like acne or insect bites. A: Bulla is a large fluid-filled blister, not a solid lesion. B: Wheal is a raised, red area of skin that is typically transient and caused by an allergic reaction. C: Nodule is a solid, elevated lesion that is greater than 1 cm in diameter, not less than 1 cm.

Correct Answer: B

Rationale: The correct answer is B because asking about future plans post-hospital discharge assesses judgment by evaluating the individual's ability to make considered decisions and anticipate consequences. Choice A focuses on paranoia, not judgment. Choice C assesses interpretation skills, not judgment. Choice D evaluates honesty or ethics, not judgment. Therefore, B is the best choice for assessing judgment.

Correct Answer: D

Rationale: The correct answer is D because a health history aims to gather subjective information about a patient's past and current health. It helps in understanding the patient's health concerns, medical history, lifestyle factors, and other relevant information. By collecting this data, healthcare providers can make informed decisions regarding the patient's care. Option A is incorrect as the purpose is more than just interaction. Option B is incorrect as it focuses solely on biographical information. Option C is incorrect as it pertains to physical assessment findings, not subjective health information.