health assessment exam 2 test bank

Correct Answer: A

Rationale: The correct answer is A. Encouraging early ambulation and use of compression stockings is crucial post-abdominal surgery to prevent complications like deep vein thrombosis and pneumonia. Ambulation helps prevent blood clots and promotes lung expansion. Compression stockings aid in preventing blood pooling in the legs. Administering pain medication regularly (B) is important but not the priority. Monitoring for infection (C) is essential but not the priority immediately post-op. Providing nutritional support and hydration (D) is important but not as critical as preventing immediate complications.

Correct Answer: B

Rationale: The correct answer is B because it shows empathy and validation towards the patient's emotions. By acknowledging the patient's sadness and giving her permission to cry, the nurse creates a safe and supportive environment. This response helps the patient feel understood and accepted, facilitating emotional expression and potentially leading to a deeper therapeutic relationship. Choice A is incorrect because it focuses on the nurse's discomfort rather than the patient's feelings. Choice C is incorrect as it may come across as dismissive of the patient's emotions. Choice D is incorrect as it suggests avoiding the topic rather than addressing the patient's feelings directly.

Correct Answer: A

Rationale: The correct answer is A because increased sputum production and shortness of breath are classic signs of exacerbation in COPD. This indicates worsening airflow limitation and potential respiratory distress. Monitoring these signs helps in early intervention and preventing further complications. B: Improved oxygen saturation is not a sign of exacerbation in COPD. It would actually suggest improvement in the patient's condition. C: Increased energy levels are not typical signs of exacerbation in COPD. Patients usually experience fatigue and weakness during exacerbations. D: Decreased respiratory rate is not indicative of exacerbation in COPD. It could be a sign of respiratory depression or sedation, but not exacerbation.

Correct Answer: B

Rationale: The correct answer is B: It was a nontherapeutic response. The nurse responded in a way that downplayed the patient's concerns and shut down the conversation. Rationale: 1. The nurse's response of dismissing the woman's fear and immediately shifting the focus to medication options invalidates the woman's feelings. 2. By sharing her own experience without acknowledging the woman's emotions, the nurse fails to provide genuine support. 3. The response lacks empathy and fails to address the woman's emotional needs, thus hindering effective communication. 4. This type of response may discourage the woman from expressing her concerns openly in the future, leading to potential emotional distress. Summary of other choices: A: Incorrect. Sharing personal experience alone does not make it therapeutic. In this context, it did not address the woman's emotional concerns effectively. C: Incorrect. Providing information about medications, although helpful, does not address the woman's emotional distress and fears. D: Incorrect. While the response did minimize the patient

Correct Answer: C

Rationale: The correct answer is C: mental health issues. When taking a family history, mental health issues are important as they can have a genetic component and can impact the patient's overall health. Emphysema (A) is a respiratory condition, head trauma (B) is not typically hereditary, and fractured bones (D) are usually due to accidents or osteoporosis, not genetic.