health assessment exam 2 test bank

Correct Answer: A

Rationale: The correct answer is A: Administering diuretics as prescribed. Diuretics help reduce fluid retention in patients with heart failure, relieving symptoms like edema and shortness of breath. Prioritizing diuretics can help manage the patient's fluid balance and improve heart function. Encouraging increased fluid intake (B) is contraindicated as it can worsen fluid overload. Restricting sodium intake (C) is important in heart failure management but not the top priority over administering diuretics. Administering pain medications (D) is not a priority intervention for chronic heart failure management.

Correct Answer: D

Rationale: The correct answer is D: Pitting edema and weight gain. In chronic heart failure, worsening symptoms indicate fluid retention. Pitting edema in the extremities and weight gain are signs of fluid overload, indicating worsening heart failure. It is crucial for the nurse to monitor these signs to prevent exacerbation. Fatigue and shortness of breath (Choice A) are common symptoms in heart failure but not specific to worsening condition. Increased urine output (Choice B) is not typically seen in worsening heart failure as the kidneys may be compromised. Decreased blood pressure (Choice C) can occur in acute decompensation but is not a consistent sign of worsening chronic heart failure.

Correct Answer: A

Rationale: The correct answer is A: "I will inspect my feet daily for cuts or blisters." This statement indicates proper understanding because daily foot inspection is crucial for early detection of any wounds, which can prevent complications in diabetic patients. Incorrect choices: B: Avoiding trimming toenails can lead to ingrown nails and potential injury. C: Wearing tight shoes can increase the risk of blisters and discomfort. D: Ignoring small wounds can lead to infections and more serious foot issues. In summary, choice A is correct as it promotes proactive foot care, while the other choices can potentially harm the patient's foot health.

Correct Answer: A

Rationale: The correct answer is A: Encouraging early ambulation. Early ambulation helps prevent complications such as deep vein thrombosis and pulmonary embolism by improving circulation and preventing blood clots. It also promotes joint mobility and muscle strength. Providing pain medication (B) is important but not as crucial as preventing complications. Monitoring for signs of infection (C) is essential but not the most important intervention. Administering antibiotics before surgery (D) does not directly prevent post-operative complications related to knee replacement.

Correct Answer: D

Rationale: The correct answer is D because the patient is showing signs of expressive aphasia, where they have difficulty with verbal expression. By supporting his efforts to communicate and using pantomime and gestures, the nurse can help bridge the communication gap and facilitate understanding. This approach acknowledges the patient's drive to communicate and helps him convey his thoughts effectively. Option A is incorrect because although the patient may understand, the nurse needs to adapt the communication method to support the patient's expressive difficulties. Option B is incorrect as abandoning communication efforts would be detrimental to the patient's well-being and recovery. Option C is incorrect as the patient's ability to read and write may also be impaired due to the stroke, making this method less effective than using gestures and pantomime.