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: A

Rationale: The correct answer is A because it helps differentiate between orthopnea (difficulty breathing when lying down) and paroxysmal nocturnal dyspnea (sudden awakening due to difficulty breathing). By asking about worsening symptoms when lying down, the nurse can assess if the patient has orthopnea, a classic symptom of heart failure. Choices B, C, and D are incorrect because they do not specifically target the nighttime breathing difficulty associated with heart failure.

Correct Answer: C

Rationale: The correct immediate intervention for a hypoglycemic client is to provide 4-6 ounces of fruit juice with sugar. This is because the client needs a quick source of glucose to raise their blood sugar levels rapidly. Fruit juice with sugar is easily absorbed, providing a fast-acting solution to hypoglycemia. Commercially prepared glucose tablets may take longer to be absorbed than fruit juice. Hard candies and honey may not contain enough sugar to raise blood sugar levels quickly compared to fruit juice. Therefore, fruit juice with sugar is the most effective option for immediate intervention in hypoglycemic clients.

Correct Answer: D

Rationale: Rationale: 1. Altered family processes impact an infant's body image due to the emotional response and support provided by family members. 2. Positive family dynamics can help the infant cope with the diagnosis and build self-esteem. 3. Conversely, negative family processes may lead to feelings of inadequacy and affect body image. 4. Immobility, altered growth, and hemarthrosis are physical factors but do not directly influence body image. Summary: Altered family processes have the most significant impact on an infant's body image as they shape emotional support and self-perception. Immobility, altered growth, and hemarthrosis are important considerations but are not as directly related to body image in this context.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.