advanced health assessment test bank

Correct Answer: C

Rationale: The correct answer is C: Hypotension and tachycardia. In acute pancreatitis, complications like hypovolemic shock can lead to hypotension and tachycardia due to fluid shifts and inflammation. Decreased urine output and increased thirst (A) may indicate dehydration but are not specific to pancreatitis. Increased blood pressure and heart rate (B) are not typical signs of complications in pancreatitis. Tachypnea and cyanosis (D) suggest respiratory distress, which is not a common complication of pancreatitis.

Correct Answer: A

Rationale: The correct answer is A because when a patient is experiencing significant shortness of breath, the nurse should initially focus on assessing the areas directly related to the presenting problem to address the immediate issue. This approach allows for prompt intervention and treatment of the patient's acute condition. Once the patient's respiratory distress is managed, the nurse can then proceed with a complete assessment to identify any underlying or additional health issues. This stepwise approach ensures that the patient's urgent needs are met first before conducting a comprehensive assessment. Choices B, C, and D are incorrect because: B: Performing a mini-database by only examining body areas directly related to the problem may not provide a comprehensive understanding of the patient's condition and could overlook other potential health issues. C: Dismissing significant shortness of breath as a normal finding and proceeding with an abdominal assessment is inappropriate and could delay necessary interventions for the respiratory distress. D: Examining the entire body to determine if the problem is linked to something else is inefficient and

Correct Answer: C

Rationale: The correct answer is C because it demonstrates a rapid succession of loosely associated thoughts, typical of flight of ideas. The statement transitions from discussing a pill to the color red, then red velvet, and finally to a baby's bottom. This rapid and disjointed flow of thoughts is characteristic of flight of ideas, a symptom commonly seen in manic episodes of bipolar disorder. Choices A, B, and D do not exhibit the same level of rapid and tangential thoughts as choice C, making them incorrect.

Correct Answer: C

Rationale: The correct answer is C: Respiratory failure. For a patient with chronic asthma, the priority complication to monitor for is respiratory failure as it can be life-threatening. Asthma is a chronic respiratory condition that can lead to severe bronchoconstriction and impaired gas exchange, potentially resulting in respiratory failure. Monitoring for signs such as increased respiratory rate, use of accessory muscles, decreased oxygen saturation, and altered mental status is crucial. Pneumothorax (A) is a possible complication but less common in chronic asthma. Hyperglycemia (B) and chronic renal failure (D) are not directly related to asthma and are not the primary complications to monitor for in this case.

Correct Answer: C

Rationale: The correct answer is C: Hypotension and tachycardia. In acute pancreatitis, complications like hypovolemic shock can lead to hypotension and tachycardia due to fluid shifts and inflammation. Decreased urine output and increased thirst (A) may indicate dehydration but are not specific to pancreatitis. Increased blood pressure and heart rate (B) are not typical signs of complications in pancreatitis. Tachypnea and cyanosis (D) suggest respiratory distress, which is not a common complication of pancreatitis.