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: C

Rationale: The correct answer is C because spirituality is a personal and intrinsic search for meaning and purpose in life, which is central to the human experience. This definition aligns with the concept of spirituality as a journey of self-discovery and reflection, independent of organized religion or cultural background. Explanation for why other choices are incorrect: A: Worshiping a higher power within an organization implies a religious practice rather than spirituality, which is more individualistic and introspective. B: Attendance at a specific house of worship is a religious practice, not necessarily reflective of spirituality, which can exist outside formal religious institutions. D: While spirituality can be influenced by cultural background, it is not solely tied to it, as it transcends social, ethnic, and historical boundaries.

Correct Answer: D

Rationale: The correct answer is D because obtaining information on the limitations related to the girl's involvement in sports activities is crucial for assessing her overall physical health and well-being. This information helps in understanding any potential risks or issues that may arise from her participation in sports. Choices A, B, and C are incorrect as they are not relevant to a review of systems for a healthy 7-year-old girl. Glaucoma examination, breast self-examination frequency, and electrocardiogram date are not typically part of a routine review of systems for a child of her age and health status.

Correct Answer: C

Rationale: The correct answer is C because stopping medication without consulting a healthcare provider can lead to uncontrolled hypertension. Choice A shows understanding of monitoring blood pressure, B demonstrates adherence to medication regimen, and D indicates awareness of dietary management. Choice C is incorrect because abruptly stopping medication can have serious health consequences, making further education necessary.

Correct Answer: D

Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness. Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.