health assessment test bank jarvis

Correct Answer: B

Rationale: The correct answer is B because critical thinking involves anticipating potential issues to provide proactive care. By predicting potential problems, nurses can prevent complications and tailor interventions accordingly. This step is essential in the nursing process to ensure comprehensive and effective care. Continuing to reassess (A) is important but not the primary focus of a nursing diagnosis. Checking the appropriateness of goals (C) is crucial but comes after identifying the problem and predicting potential issues. Modifying the diagnosis if necessary (D) is a part of critical thinking but not the immediate next step after identifying the actual problem.

Correct Answer: A

Rationale: The correct answer is A because a comprehensive assessment involves gathering a complete health history and conducting a thorough physical examination to evaluate the client's overall health status. This includes assessing past medical history, family history, current medications, lifestyle factors, and performing a head-to-toe physical examination. This holistic approach helps in identifying any potential health issues or risk factors. Choice B is incorrect because a specific focus on a body system is not comprehensive and may miss other important aspects of the client's health. Choice C is incorrect as emergency triage is a rapid assessment to determine the severity of a medical condition and prioritize treatment, not a comprehensive assessment. Choice D is incorrect because a specific assessment of client complaints is focused only on the reported issues and may not provide a comprehensive overview of the client's health.

Correct Answer: B

Rationale: The correct answer is B because critical thinking involves anticipating potential issues to provide proactive care. By predicting potential problems, nurses can prevent complications and tailor interventions accordingly. This step is essential in the nursing process to ensure comprehensive and effective care. Continuing to reassess (A) is important but not the primary focus of a nursing diagnosis. Checking the appropriateness of goals (C) is crucial but comes after identifying the problem and predicting potential issues. Modifying the diagnosis if necessary (D) is a part of critical thinking but not the immediate next step after identifying the actual problem.

Correct Answer: C

Rationale: Rationale: C: Reinforce the dressing is the correct intervention for serosanguineous drainage after cholecystectomy. This helps maintain a clean and dry wound environment, promotes healing, and prevents infection. Changing the dressing (B) may disrupt the wound healing process. Notifying the physician (A) is important but not the immediate intervention. Applying an abdominal binder (D) is not indicated for managing serosanguineous drainage.

Correct Answer: D

Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.