health assessment in nursing test bank

Correct Answer: D

Rationale: The correct answer is D: Respiratory failure. In chronic asthma, persistent inflammation and airway remodeling can lead to worsening lung function and respiratory distress, ultimately resulting in respiratory failure. Monitoring for signs of respiratory distress such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial. A: Hypoglycemia is not a typical complication of asthma. B: Oxygen toxicity is not a common complication in asthma management unless high concentrations of supplemental oxygen are administered for prolonged periods. C: Hyperkalemia is not directly associated with asthma but may occur as a complication of certain asthma treatments or comorbid conditions. Therefore, the priority complication to monitor in a patient with chronic asthma is respiratory failure due to the progressive nature of the disease and the potential for acute exacerbations.

Correct Answer: C

Rationale: The correct answer is C because determining if the patient can afford her medications is crucial in managing her diabetes effectively. Financial constraints can significantly impact a patient's ability to adhere to treatment, leading to poor health outcomes. By addressing affordability, the nurse can ensure the patient can access and comply with the prescribed medications. A, finding out why the patient is not compliant, is not the priority at this stage as addressing affordability comes first. B, reinforcing health teaching related to diet and exercise, is important but secondary to ensuring access to medications. D, sending the patient to the diabetic clinic for follow-up, is not as critical as addressing immediate financial concerns.

Correct Answer: D

Rationale: The correct answer is D: Inappropriate affect. Inappropriate affect refers to emotions that are not congruent with the situation. In this case, the patient's laughing while describing a horrifying image indicates a disconnect between his emotions and the context. This behavior is commonly seen in schizophrenia, where there is a lack of appropriate emotional response. A: Confusion does not accurately describe the patient's behavior, as he is able to describe the picture and his emotional response to it. B: Ambivalence refers to conflicting emotions or attitudes, which is not evident in the patient's behavior. C: Depersonalization involves feeling detached from oneself or reality, which is not evident in the patient's behavior. In summary, the patient's inappropriate laughter in response to a horrifying image is indicative of inappropriate affect, a common feature of schizophrenia.

Correct Answer: B

Rationale: The correct answer is B: Ambulation as soon as possible after surgery. Ambulation helps prevent complications like blood clots and aids in circulation and muscle strength. Bed rest can lead to stiffness and decrease in range of motion. Limiting physical activity delays recovery. Prolonged use of a cast can hinder mobility and delay rehabilitation.

Correct Answer: A

Rationale: The correct answer is A: Cold, dry air. Asthma patients are often triggered by cold, dry air, which can cause airway constriction and worsen symptoms. Warm, humid air can actually help alleviate symptoms by keeping airways moist. Excessive physical activity can also trigger asthma, but it varies among individuals and can be managed with appropriate medication and monitoring. Choice D is incorrect as warm, humid air is not a trigger for asthma.