jarvis health assessment test bank

Correct Answer: A

Rationale: Correct answer: A - Hyperkalemia Rationale: 1. In CKD, impaired kidney function leads to decreased potassium excretion, causing hyperkalemia. 2. Hyperkalemia can result in life-threatening cardiac arrhythmias. 3. Monitoring potassium levels is crucial in CKD management. Summary: B: Hypoglycemia - Not typically associated with CKD, more common in diabetes. C: Hyperglycemia - Common in diabetes, but not a typical complication of CKD. D: Hypercalcemia - Uncommon in CKD, more often seen in hyperparathyroidism.

Correct Answer: A

Rationale: The correct answer is A: Cleanse and dress the wound. This intervention is essential as it helps prevent infection, promotes healing, and maintains a moist wound environment. Cleansing removes debris and bacteria, while dressing protects the wound from external contaminants. Administering antibiotics (choice B) is not the initial intervention for an open wound. Placing a sterile dressing (choice C) is important, but cleansing the wound first is crucial. Ensuring wound care is sterile (choice D) is important, but the primary focus should be on cleansing and dressing the wound.

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. At 11-12 months, a child should be able to pull themselves to a standing position. Inability to do so suggests possible hip joint instability, a key risk factor for developmental dysplasia of the hip. Refusal to walk (A) is not specific to hip dysplasia. Negative Trendelenburg sign (C) indicates good hip abductor strength, which is not a risk factor. Negative Ortolani sign (D) is a maneuver used for hip joint assessment in infants and is not indicative of hip dysplasia risk at this age.

Correct Answer: C

Rationale: The correct answer is C: Pulmonary edema. In chronic heart failure, the heart cannot pump blood effectively, leading to fluid buildup in the lungs causing pulmonary edema. Monitoring for signs such as shortness of breath, wheezing, and crackles can help prevent respiratory distress. Incorrect choices: A: Hypoglycemia - Not directly related to chronic heart failure. B: Hyperkalemia - Can occur in heart failure but not a primary complication to monitor for. D: Anemia - Can be a consequence of chronic heart failure but not a primary complication to monitor for.

Correct Answer: A

Rationale: Administering aspirin is the most appropriate intervention for a client experiencing a heart attack. Aspirin helps prevent blood clot formation, which is crucial in reducing further damage to the heart during a heart attack. It inhibits platelets from clumping together, improving blood flow to the heart muscle. Thrombolytics are used to dissolve existing blood clots, but aspirin is more preventive. Monitoring for arrhythmias is important but not the initial intervention. Administering morphine can be considered for pain relief but is not as crucial as administering aspirin to prevent further clot formation.