health assessment test bank jarvis

Correct Answer: A

Rationale: The correct answer is A: Neutropenia. During chemotherapy, neutropenia, a decrease in white blood cells, can occur, leading to increased risk of infections. Monitoring for neutropenia is crucial for timely intervention. Hyperkalemia (B) is not commonly associated with chemotherapy. Hypoglycemia (C) is more related to diabetes or insulin therapy. Chronic pain (D) is not a typical complication of chemotherapy. Monitoring for neutropenia allows the nurse to provide appropriate care to prevent infections and ensure the patient's safety.

Correct Answer: A

Rationale: The correct answer is A: Kidney function tests. In diabetic nephropathy, the kidneys are affected, leading to impaired kidney function. Monitoring kidney function tests such as serum creatinine and glomerular filtration rate is crucial to assess the progression of the disease and guide treatment. Blood pressure measurement (B) is important in managing diabetic nephropathy but does not directly assess kidney function. Blood glucose levels (C) are essential in managing diabetes overall but do not specifically address nephropathy. Urine output monitoring (D) is important for assessing kidney function but does not provide as comprehensive information as kidney function tests.

Correct Answer: D

Rationale: The correct answer is D: Head to toe. The head-to-toe assessment is efficient because it follows a systematic approach starting from the head and progressing downward, ensuring that all body parts are assessed while maintaining the patient's modesty. This approach allows the nurse to gather comprehensive data without compromising the patient's privacy. A: Body systems - While assessing by body systems is important, it may not provide the same level of modesty as the head-to-toe approach. B: Functional - Assessing by function focuses on specific body functions rather than a comprehensive assessment of all body systems. It may not address all aspects of the patient's health. C: Focused - A focused assessment targets specific health issues and may not cover all body systems comprehensively, potentially missing important findings.

Correct Answer: D

Rationale: Correct Answer: D - Administering oxygen Rationale: 1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload. 2. Administering oxygen helps alleviate ischemia and prevents further damage. 3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being. Summary of other choices: A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction. B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation. C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Increased white blood cell count. When a client has an infection, the body's immune response triggers an increase in white blood cells to help fight off the infection. Neutrophils and band cells (choice B) may also increase during infection, but a general increase in white blood cells is a more reliable indicator. ESR (choice C) is a nonspecific marker of inflammation and may be elevated in various conditions, not just infection. LDH (choice D) is an enzyme found in many tissues and can be elevated in various conditions, not specifically infection. Therefore, an increased white blood cell count is the most indicative of infection in a client with a fever.