advanced health assessment test bank

Correct Answer: B

Rationale: Step 1: Recognize Cultural Sensitivity - Understanding that family inclusion is a cultural practice is crucial as it helps the nurse appreciate the patient's perspective. Step 2: Empathy - Acknowledging the significance of family involvement for the patient shows empathy and respect for their beliefs and values. Step 3: Effective Communication - By recognizing and respecting the cultural practice, the nurse can build a trusting relationship with the patient and her family, leading to better adherence to medication and improved care outcomes. In summary, Option B is correct as it emphasizes cultural competence and patient-centered care. Options A, C, and D are incorrect as they do not address the core issue of cultural understanding and may hinder effective communication and relationship-building with the patient and her family.

Correct Answer: A

Rationale: The correct answer is A: Oxygen saturation levels. This assessment is crucial in pneumonia to ensure adequate oxygenation. Low oxygen levels can lead to respiratory distress. Pain levels (B) are important but not a priority over oxygenation. Bowel sounds (C) are not directly related to pneumonia. Level of consciousness (D) is also important but not as critical as ensuring proper oxygen levels for a patient with pneumonia. Oxygen saturation levels should be prioritized to prevent complications and ensure the patient's respiratory status is stable.

Correct Answer: C

Rationale: The correct answer is C: Give him the Four Unrelated Words Test. This is the best way to assess new memory because it is a standardized test specifically designed to evaluate a patient's ability to form new memories. The test involves presenting the patient with four unrelated words and then asking them to recall those words after a delay. This test is reliable, valid, and widely used in clinical settings to assess new memory formation. Other choices are incorrect because: A: Administering the FACT test is not the best way to assess new memory as it is not specifically designed for this purpose. B: Asking the patient to describe his first job does not directly evaluate new memory formation and may not provide a standardized assessment. D: Asking the patient to describe the last TV show he watched does not focus on new memory and is not a standardized way to assess memory function.

Correct Answer: D

Rationale: The correct answer is D: "What cultural or spiritual beliefs are important to you?" This question allows the nurse to understand the elder's values and beliefs, guiding care. A: Assumes a specific faith. B: Stereotypes the elder. C: Focuses on frequency of medical visits, not beliefs.

Correct Answer: D

Rationale: The correct answer is D, as limiting alcohol and reducing sodium intake are crucial lifestyle modifications for managing hypertension. Alcohol can raise blood pressure, while excess sodium can increase fluid retention and elevate blood pressure. Monitoring blood pressure regularly (choice A) is important but alone does not indicate understanding of lifestyle modifications. Taking medication as prescribed (choice B) is essential but does not address lifestyle changes. Stopping medication if blood pressure is normal (choice C) is dangerous, as hypertension often requires ongoing treatment. In summary, choice D addresses key lifestyle modifications necessary for managing hypertension, while the other choices do not fully demonstrate understanding of proper management strategies.