jarvis health assessment test bank

Correct Answer: A

Rationale: The correct answer is A because it focuses on prioritizing the assessment by first addressing the immediate problem of shortness of breath. By examining only the body areas related to the current issue, the nurse can quickly gather essential information to manage the patient's respiratory distress effectively. Once the critical issue is stabilized, a complete assessment can be conducted to identify any underlying problems or potential complications. This approach ensures that the nurse addresses the most urgent needs first before proceeding to a comprehensive assessment. Choice B is incorrect because it suggests only examining body areas directly related to the hospitalization problem, which may overlook other critical issues contributing to the shortness of breath. Choice C is incorrect as shortness of breath is not a normal finding and should not be dismissed without further evaluation. Choice D is incorrect as examining the entire body without focusing on the immediate issue may delay appropriate interventions for the patient's respiratory distress.

Correct Answer: A

Rationale: The correct answer is A: Perform a lumbar puncture. This is the first action because diagnosing meningitis requires cerebrospinal fluid analysis obtained through a lumbar puncture. It helps identify the specific type of meningitis (bacterial, viral, or fungal) and guides appropriate treatment. Administering pain relief (B) or oxygen (C) may be necessary but not the initial priority. Administering antibiotics (D) should be based on the results of the lumbar puncture to ensure targeted therapy.

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: Administer fluids. In shock, the most crucial intervention is to restore perfusion by increasing circulating volume. Administering fluids helps to improve tissue perfusion and oxygen delivery. This is essential for stabilizing the client's condition. Monitoring cardiac rhythm (B) and blood pressure (C) are important, but addressing the underlying issue of hypovolemia by giving fluids takes precedence. Providing IV antibiotics (D) is not the primary intervention for shock, as the immediate focus should be on restoring blood flow and oxygen delivery.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates cultural competence and respect for the patient's beliefs. It shows willingness to accommodate the patient's request, promoting trust and effective communication. Choice B is incorrect as it dismisses the patient's request and may lead to distrust. Choice C is incorrect as it disregards the patient's cultural beliefs and can be perceived as insensitive. Choice D is incorrect as it invalidates the patient's beliefs and can hinder the therapeutic relationship. Ultimately, choice A is the most appropriate response to promote patient-centered care and build a trusting relationship with the patient.