advanced health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Encouraging regular foot inspections. This is the priority intervention because diabetic neuropathy can lead to decreased sensation in the feet, increasing the risk of injury or infection. Regular foot inspections can help detect any issues early and prevent complications. Incorrect choices: B: Providing additional protein to the diet - While nutrition is important for overall health, providing additional protein does not directly address the specific issue of diabetic neuropathy. C: Encouraging weight loss to reduce joint stress - Weight loss may be beneficial for overall health, but it is not the priority intervention for diabetic neuropathy. D: Administering pain medication for relief - Pain management is important, but addressing the root cause through regular foot inspections is more essential in preventing further complications.

Correct Answer: D

Rationale: The correct answer is D because the patient's behavior of not making eye contact and looking down can be a sign of active listening and respect in some cultures, including many First Nations cultures. This behavior may indicate that the patient is focusing on what the nurse is saying and showing attentiveness. Making eye contact may be considered disrespectful or challenging in some cultures, so the lack of eye contact does not necessarily mean the patient has something to hide, is ashamed, or is nervous. Choice A assumes the patient is nervous or embarrassed without evidence. Choice B is an assumption without any basis, and choice C does not consider cultural differences in communication styles.

Correct Answer: B

Rationale: The correct answer is B because the inspection phase of a physical assessment involves visually examining the patient's body, which can reveal a surprising amount of information. This step is crucial in identifying visible abnormalities, such as skin discoloration, swelling, or asymmetry. It helps in assessing the patient's overall appearance, posture, and body movements. This detailed observation can provide valuable insights into the patient's health status and aid in making an accurate diagnosis. Choice A is incorrect because the inspection phase actually provides significant information. Choice C is incorrect as it downplays the importance of thorough observation. Choice D is incorrect because the discomfort level for the expert practitioner is not a defining factor in the inspection phase.

Correct Answer: C

Rationale: The correct answer is C, hypercapnia. In COPD, impaired lung function leads to inadequate oxygen exchange, causing increased carbon dioxide levels in the blood (hypercapnia). This can result in respiratory acidosis and further exacerbate respiratory distress. Monitoring for hypercapnia is crucial in COPD management to prevent respiratory failure. Incorrect choices: A: Pulmonary embolism - While patients with COPD are at increased risk for blood clots, pulmonary embolism is not a direct complication of COPD. B: Pneumothorax - Although individuals with COPD may develop pneumothorax due to weakened lung tissue, it is not a common complication. D: Asthma attack - Asthma and COPD are distinct conditions with different pathophysiology. Asthma attacks are not a typical complication of COPD.

Correct Answer: B

Rationale: The correct answer is B: I will rotate injection sites to avoid tissue damage. This statement indicates proper understanding because rotating injection sites helps prevent tissue damage and ensures consistent absorption. Injecting into the same spot every time can lead to lipohypertrophy. Injecting insulin only when blood glucose is elevated is incorrect as insulin is needed regularly. Injecting into the arm for faster absorption is also incorrect, as it can lead to unpredictable absorption rates. Rotation of sites is crucial for optimal insulin absorption and to prevent complications.