jarvis health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin helps prevent further clot formation by inhibiting platelet aggregation, reducing the risk of additional heart damage. It is a standard treatment in acute myocardial infarction. Administering morphine (B) may be considered for pain relief but is not the primary intervention. Monitoring vital signs (C) is important, but not the primary intervention. Administering fibrinolytics (D) is indicated in certain cases but is not the primary intervention and requires specific criteria and caution.

Correct Answer: C

Rationale: The correct answer is C: Severity. In the PQRSTU mnemonic, "S" stands for Severity, which refers to the intensity or seriousness of the symptoms experienced by the patient. This is crucial in assessing the impact of the problem on the patient's health and well-being. Incorrect choices: A: Swelling - Swelling is a physical symptom and does not encompass all aspects of the patient's perception. B: Subjectivity - While the patient's subjective experience is important, it does not specifically refer to severity. D: Symptoms - While symptoms are part of the patient's perception, the "S" in PQRSTU specifically focuses on the severity of those symptoms.

Correct Answer: A

Rationale: The correct answer is A: Administer antihypertensive medication. In a hypertensive emergency, the priority is to lower blood pressure quickly to prevent organ damage. Antihypertensive medications like nitroprusside or labetalol are used for this purpose. Placing the client in a comfortable position and administering oxygen (B) may be beneficial, but lowering the blood pressure is the primary action. Monitoring blood pressure and administering antihypertensive medication (C) is correct, but the emphasis should be on immediate intervention. Monitoring the client's ECG (D) is important but not the primary action in a hypertensive emergency.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Sodium restriction helps prevent fluid retention and high blood pressure in CKD. 2. Limiting sodium intake is crucial in managing CKD-related complications. 3. Excess sodium can worsen fluid retention and strain the kidneys. 4. Proper understanding of sodium limitation shows patient's grasp of CKD management. Incorrect Choices: B. Increasing fluid intake can worsen fluid retention in CKD patients. C. Excessive protein intake can burden the kidneys in CKD. D. High potassium levels in CKD can lead to dangerous heart rhythm abnormalities.