jarvis physical examination and health assessment 9th edition test bank

Correct Answer: B

Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This is the best action because it allows the nurse to assess for potential underlying issues such as pneumothorax or pleural effusion which could be causing the respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the chest. Choice A is incorrect because simply counting respirations does not provide immediate information on the cause of distress. Choice C is incorrect as inspecting for masses and bleeding does not directly address the urgency of the situation. Choice D is incorrect as waiting for a chest x-ray would delay necessary interventions in a critical situation.

Correct Answer: C

Rationale: The correct answer is C because a risk diagnosis involves identifying potential problems that an individual may develop in the future. This type of diagnosis focuses on preemptive measures to prevent or minimize the risk of these potential issues occurring. This is different from options A, B, and D, which do not pertain to future potential problems but rather current levels of wellness, past problems and goals, and strengths respectively. Therefore, option C best aligns with the concept of risk diagnosis in nursing classification.

Correct Answer: A

Rationale: The correct answer is A. Regularly checking blood glucose levels is crucial for diabetic patients to monitor their condition and adjust treatment as needed. This helps in managing blood sugar levels effectively and preventing complications. Choice B is incorrect because stopping insulin abruptly can lead to dangerous fluctuations in blood sugar levels. Choice C is incorrect because while exercise is important for diabetic patients, vigorous exercise every day may not be suitable for everyone and should be discussed with healthcare providers. Choice D is incorrect as carbohydrates are an essential source of energy and nutrients for the body. Diabetic patients can still consume carbohydrates in controlled portions as part of a balanced diet.

Correct Answer: D

Rationale: The correct answer is D because it directly addresses the inappropriate behavior, sets a boundary, and communicates the nurse's discomfort in a professional manner. By stating that the comment makes them uncomfortable and asking the patient to refrain from such behavior, the nurse asserts their professionalism while maintaining respect for both parties. Choice A is too abrupt and may escalate the situation. Choice B dismisses the behavior, which is inappropriate. Choice C could be perceived as confrontational and potentially lead to a defensive response from the patient.

Correct Answer: A

Rationale: Correct Answer: A - Encouraging early ambulation Rationale: 1. Early ambulation helps prevent post-operative complications like blood clots and pneumonia. 2. Movement promotes circulation, aids in lung expansion, and prevents muscle atrophy. 3. It also supports bowel function and helps prevent constipation, a common post-operative issue. 4. Ambulation aids in overall recovery and reduces the risk of complications associated with prolonged immobility. Other Choices: B: Administering pain medication - Important for comfort but not the top priority for preventing complications. C: Providing wound care and dressing changes - Necessary for wound healing but not the immediate priority to prevent complications. D: Monitoring for signs of infection - Critical but not the primary intervention to prevent complications immediately post-op.