health assessment exam 1 test bank

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Post-operative hip replacement patients are at high risk for DVT due to immobility and surgical trauma. The nurse should monitor for signs such as swelling, redness, and pain in the affected leg. DVT can lead to serious complications like pulmonary embolism if not detected early. Choices A, C, and D are incorrect because while pneumonia, wound infection, and hypoglycemia are also potential post-operative complications, they are not as directly associated with hip replacement surgery as DVT.

Correct Answer: C

Rationale: The correct answer is C. After a stroke, patients need to be evaluated by a healthcare professional before resuming driving. This is crucial to ensure the safety of the patient and others on the road. Choice A shows medication compliance, B demonstrates follow-up care, and D emphasizes monitoring symptoms, all of which are essential post-stroke. However, choice C indicates a lack of understanding about the importance of medical clearance before driving, hence the need for further education.

Correct Answer: A

Rationale: The correct answer is A because documenting the findings is essential for accurate patient care and communication among healthcare professionals. By documenting the unfamiliar sound heard during auscultation, the nurse ensures that the information is recorded for future reference and potential follow-up assessments or interventions. Waiting 10 minutes (B) may not address the immediate need for documentation. Asking another nurse to double-check (C) may be helpful but does not address the importance of documenting the finding. Asking the patient to take deep breaths (D) is not the appropriate next step when an unfamiliar heart sound is detected; documentation is crucial before further assessment or intervention.

Correct Answer: D

Rationale: The correct answer is D: "Please describe what happens to you when you take penicillin." This response allows the nurse to gather detailed information about the patient's allergic reaction to penicillin, which is crucial for assessing the severity of the allergy and determining appropriate treatment options. By understanding the specific symptoms experienced by the patient, the nurse can help prevent potential adverse reactions in the future. Choices A, B, and C are incorrect because: A: This question does not address the immediate concern of the patient's penicillin allergy and does not help in understanding the nature of the allergic reaction. B: The frequency of penicillin usage is not as relevant as understanding the nature and severity of the allergic reaction. C: While recording allergy information is important, it does not address the need for understanding the patient's specific allergic response to penicillin.

Correct Answer: D

Rationale: The correct answer is D: Subjective data. During the interview portion of data collection, subjective data is obtained as it involves personal opinions, feelings, and experiences shared by the interviewee. This data is based on individual perspectives and cannot be measured objectively. Physical data (A) refers to tangible measurements, historical data (B) relates to past events or records, and objective data (C) is based on observable and measurable facts. In contrast, subjective data (D) captures the interviewee's viewpoints and interpretations, making it the most appropriate choice for the given scenario.