health assessment exam 1 test bank

Correct Answer: A

Rationale: The correct answer is A: Administering antihypertensive medication as prescribed. This is the priority intervention because it directly addresses the patient's hypertension, which is a critical condition that needs immediate management to prevent complications. Encouraging weight loss (B), monitoring blood pressure (C), and promoting a low-sodium diet (D) are all important aspects of managing hypertension. However, administering antihypertensive medication takes precedence as it directly targets lowering blood pressure and reducing the risk of cardiovascular events. Weight loss, monitoring, and dietary changes are important for long-term management but may not provide immediate control of hypertension compared to medication.

Correct Answer: A

Rationale: The correct answer is A: Blood pressure and heart rate. This is crucial in assessing the cardiac function of a patient with a history of myocardial infarction. Monitoring blood pressure and heart rate helps in evaluating cardiovascular status and detecting any potential complications. Abnormal values in these parameters can indicate inadequate perfusion to the heart or other organs, which can be life-threatening. Other choices are incorrect because: B: Temperature and respiratory rate are important assessments but not the priority for a patient with a history of myocardial infarction. C: Bowel sounds and abdominal girth are more relevant for gastrointestinal issues and not a priority in this scenario. D: Urine output and skin integrity are important assessments for overall health but do not directly relate to the cardiovascular status in a patient with a history of myocardial infarction.

Correct Answer: C

Rationale: The correct answer is C. This statement indicates a misunderstanding because stopping medication once blood pressure is normal can lead to a relapse of hypertension. Step 1: Medication management is crucial for long-term control of hypertension. Step 2: Stopping medication abruptly can cause blood pressure to rise again. Step 3: Regular monitoring, limiting sodium intake, and exercising are all important aspects of hypertension management. Summary: Choices A, B, and D demonstrate good understanding of hypertension management, while choice C shows a need for further education on the importance of continued medication use.

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: A

Rationale: The correct answer is A: Jaundice. In chronic liver disease, impaired liver function can result in the accumulation of bilirubin leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial in assessing the progression of liver disease. B: Hypoglycemia is not a common complication of chronic liver disease. Liver plays a role in glycogen storage and glucose production, so hypoglycemia is less likely. C: Hyperglycemia is more commonly associated with conditions like diabetes rather than chronic liver disease. The liver's role in glucose regulation may be impaired, but hyperglycemia is not a typical complication. D: Anemia is not directly related to liver disease, although it may occur as a secondary complication due to factors like decreased production of certain blood components. Monitoring for anemia is important, but jaundice is a more specific complication of chronic liver disease.