health assessment in nursing test bank

Correct Answer: C

Rationale: The correct answer is C because stopping insulin when blood glucose is normal is incorrect. Insulin is necessary for managing diabetes even when blood glucose levels are normal to prevent fluctuations. Monitoring blood glucose (A), exercising (B), and eating a balanced diet (D) are all important components of diabetes management. Stopping insulin abruptly can lead to hyperglycemia and potential complications.

Correct Answer: C

Rationale: The correct answer is C: Jaundice. Patients with chronic liver disease are at risk for developing jaundice due to impaired liver function leading to the accumulation of bilirubin. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates worsening liver function. Incorrect choices: A: Hypoglycemia - Not directly related to chronic liver disease, more commonly seen in diabetes. B: Hyperglycemia - Not typically associated with chronic liver disease unless the patient has underlying diabetes. D: Anemia - Can be a complication of chronic liver disease, but monitoring for jaundice takes priority due to its direct association with liver dysfunction.

Correct Answer: A

Rationale: The correct answer is A: Administering supplemental oxygen as needed. This is the priority intervention for a patient with COPD because it helps improve oxygenation and relieve respiratory distress, which is the main concern in COPD. Supplemental oxygen also helps reduce the workload on the heart and other organs. Encouraging physical activity (B) is important for overall health but may not be the priority in acute exacerbations. Administering antibiotics regularly (C) is not necessary unless there is a documented infection. Providing increased fluid intake (D) is important for maintaining hydration but is not the priority intervention in this case.

Correct Answer: B

Rationale: The correct answer is B because asking about future plans post-hospital discharge assesses judgment by evaluating the individual's ability to make considered decisions and anticipate consequences. Choice A focuses on paranoia, not judgment. Choice C assesses interpretation skills, not judgment. Choice D evaluates honesty or ethics, not judgment. Therefore, B is the best choice for assessing judgment.

Correct Answer: C

Rationale: The correct answer is C because determining if the patient can afford her medications is crucial in managing her diabetes effectively. Financial constraints can significantly impact a patient's ability to adhere to treatment, leading to poor health outcomes. By addressing affordability, the nurse can ensure the patient can access and comply with the prescribed medications. A, finding out why the patient is not compliant, is not the priority at this stage as addressing affordability comes first. B, reinforcing health teaching related to diet and exercise, is important but secondary to ensuring access to medications. D, sending the patient to the diabetic clinic for follow-up, is not as critical as addressing immediate financial concerns.