jarvis physical examination and health assessment 9th edition test bank

Correct Answer: B

Rationale: The correct answer is B: Increased wheezing and shortness of breath. During an asthma exacerbation, bronchial airways become inflamed and narrowed, leading to increased wheezing and shortness of breath. This is a classic sign of worsening asthma. Other choices are incorrect because: A) Decreased work of breathing is not expected in an asthma exacerbation as the patient usually struggles to breathe. C) Improved oxygen saturation is unlikely as airway obstruction can lead to decreased oxygen levels. D) Decreased sputum production is not a typical sign of asthma exacerbation; in fact, increased sputum production may occur due to airway inflammation.

Correct Answer: A

Rationale: Correct Answer: A - Encouraging early ambulation Rationale: 1. Early ambulation helps prevent post-operative complications like blood clots and pneumonia. 2. Movement promotes circulation, aids in lung expansion, and prevents muscle atrophy. 3. It also supports bowel function and helps prevent constipation, a common post-operative issue. 4. Ambulation aids in overall recovery and reduces the risk of complications associated with prolonged immobility. Other Choices: B: Administering pain medication - Important for comfort but not the top priority for preventing complications. C: Providing wound care and dressing changes - Necessary for wound healing but not the immediate priority to prevent complications. D: Monitoring for signs of infection - Critical but not the primary intervention to prevent complications immediately post-op.

Correct Answer: B

Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This is the best action because it allows the nurse to assess for potential underlying issues such as pneumothorax or pleural effusion which could be causing the respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the chest. Choice A is incorrect because simply counting respirations does not provide immediate information on the cause of distress. Choice C is incorrect as inspecting for masses and bleeding does not directly address the urgency of the situation. Choice D is incorrect as waiting for a chest x-ray would delay necessary interventions in a critical situation.

Correct Answer: C

Rationale: The correct answer is C: Circumlocution. This patient is using circumlocution, which is a communication strategy where a person describes something in a roundabout way instead of using the specific word. In this case, the patient is describing an elevator as "the thing that you step into that goes up." This is a common feature of language difficulties seen in conditions like aphasia. A: Blocking is when a person suddenly stops speaking in the middle of a sentence due to an inability to recall a word, which is not happening in this scenario. B: Neologism is the creation of new words or phrases, which is not evident here. D: Circumstantiality is a speech pattern where the person includes unnecessary details and goes off on tangents, which is not demonstrated in the patient's response.

Correct Answer: A

Rationale: The correct answer is A: Limiting sodium intake. This is crucial for a patient with hypertension as excess sodium can lead to increased blood pressure. Sodium intake should be limited to lower the risk of cardiovascular complications. B: Increasing potassium intake is beneficial, but not as critical as limiting sodium for hypertension management. C: Increasing fluid intake may or may not be necessary depending on the patient's condition, but it is not as crucial as limiting sodium for hypertension management. D: Consuming more caffeine can actually elevate blood pressure, so it is not recommended for patients with hypertension.