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: mental health issues. When taking a family history, mental health issues are important as they can have a genetic component and can impact the patient's overall health. Emphysema (A) is a respiratory condition, head trauma (B) is not typically hereditary, and fractured bones (D) are usually due to accidents or osteoporosis, not genetic.

Correct Answer: B

Rationale: The correct answer is B because deep breathing and coughing exercises help prevent complications such as atelectasis and pneumonia after abdominal surgery. By promoting lung expansion and clearing secretions, these exercises enhance oxygenation and prevent respiratory issues. Administering pain medication (A) is important but not the priority. Monitoring for infection (C) and providing wound care (D) are also crucial but come after ensuring respiratory function.

Correct Answer: A

Rationale: The correct answer is A. Encouraging early ambulation and use of compression stockings is crucial post-abdominal surgery to prevent complications like deep vein thrombosis and pneumonia. Ambulation helps prevent blood clots and promotes lung expansion. Compression stockings aid in preventing blood pooling in the legs. Administering pain medication regularly (B) is important but not the priority. Monitoring for infection (C) is essential but not the priority immediately post-op. Providing nutritional support and hydration (D) is important but not as critical as preventing immediate complications.

Correct Answer: B

Rationale: The correct answer is B: 1.5 m. This distance is known as the personal distance in communication, where most interviews take place. Personal distance allows for a comfortable level of interaction without invading personal space. Choice A (1 m) is too close and may make the patient uncomfortable. Choice C (2 m) is too far for an intimate interview setting. Choice D (3 m) is too distant and may lead to a lack of connection and understanding during the interview. Overall, B is the best choice for a nurse-patient interview to ensure a respectful and effective conversation.