health assessment exam 2 test bank

Correct Answer: B

Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In hypoglycemia, the priority is to quickly raise the patient's blood sugar levels to prevent potential complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (A) would further lower blood sugar levels, worsening the situation. Administering an oral hypoglycemic agent (C) is not appropriate in an acute hypoglycemic episode. Monitoring blood pressure (D) is important but not the priority in this situation.

Correct Answer: B

Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination. Incorrect Answers: A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention. C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion. D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.

Correct Answer: D

Rationale: The correct answer is D because the patient is showing signs of expressive aphasia, where they have difficulty with verbal expression. By supporting his efforts to communicate and using pantomime and gestures, the nurse can help bridge the communication gap and facilitate understanding. This approach acknowledges the patient's drive to communicate and helps him convey his thoughts effectively. Option A is incorrect because although the patient may understand, the nurse needs to adapt the communication method to support the patient's expressive difficulties. Option B is incorrect as abandoning communication efforts would be detrimental to the patient's well-being and recovery. Option C is incorrect as the patient's ability to read and write may also be impaired due to the stroke, making this method less effective than using gestures and pantomime.

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: D

Rationale: The correct answer is D because it respects the girl's privacy and allows her to speak freely without parental influence. By asking the parents to step out, the nurse creates a safe space for the girl to discuss any sensitive issues. Choice A may inhibit the girl's honest communication. Choice B risks the parents dominating the conversation. Choice C may make the girl uncomfortable discussing personal matters in front of her parents.