health assessment test bank jarvis

Correct Answer: B

Rationale: Step 1: Stroke patients are at increased risk for DVT due to immobility. Step 2: Monitoring for DVT signs is crucial for early detection and prevention. Step 3: Prompt intervention can prevent life-threatening complications. Step 4: Encouraging mobility (Choice A) is important but not the priority. Step 5: Administering antihypertensive meds (Choice C) may be necessary but not the priority. Step 6: Providing psychological support (Choice D) is important but not as critical as DVT monitoring.

Correct Answer: D

Rationale: The correct answer is D: unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it may indicate underlying conditions that need to be addressed before starting hormone therapy to avoid potential risks. Vaginal bleeding could be a sign of endometrial hyperplasia or cancer, which can be exacerbated by hormone therapy. Choices A, B, and C are not contraindications for hormone replacement therapy. Family history of stroke may influence the choice of therapy but not necessarily contraindicate it. Ovaries removed before age 45 and frequent hot flashes/night sweats are common indications for hormone replacement therapy to alleviate symptoms of menopause.

Correct Answer: C

Rationale: The correct answer is C: Jaundice. In chronic liver disease, the liver's ability to process bilirubin is impaired, leading to jaundice. This is characterized by a yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates liver dysfunction. Hypoglycemia (A) is not a typical complication of chronic liver disease. Hyperkalemia (B) is more commonly associated with kidney dysfunction. Anemia (D) can occur in liver disease but is not as specific a complication as jaundice. Therefore, monitoring for jaundice in a patient with chronic liver disease is essential for early detection and management of liver dysfunction.

Correct Answer: D

Rationale: The correct answer is D: Diagnostic reasoning. When formulating diagnostic statements, nurses use diagnostic reasoning to analyze data, identify patterns, and make accurate clinical judgments. This process involves critical thinking and synthesizing information to reach a conclusion. Physical assessment skills (C) are important in data collection but not the primary focus in formulating diagnostic statements. Rationale (A) refers to providing reasons or justifications and is not directly related to the diagnostic process. American Nurses Association recommendations (B) may guide nursing practice but are not specifically used in formulating diagnostic statements.

Correct Answer: B

Rationale: The correct answer is B: hamburgers. Clients with hypercholesterolemia should decrease their intake of foods high in saturated fats, like hamburgers. Saturated fats can raise LDL cholesterol levels. Broiled catfish (A) is a lean protein option, wheat bread (C) is a good source of fiber, and fresh apples (D) are a healthy fruit choice. Hamburgers (B) typically contain high levels of saturated fats from red meat and processed ingredients, making them a less ideal choice for individuals with high cholesterol.