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: D

Rationale: The correct answer is D because it shows respect for the patient's belief and promotes open communication. By asking the patient to explain more about the hot-cold theory, the nurse acknowledges the patient's perspective and builds a trusting relationship. Option A dismisses the patient's belief, risking alienation. Option B is informative but misses the opportunity to understand the patient's cultural beliefs. Option C is unprofessional and does not address the patient's concerns.

Correct Answer: B

Rationale: The correct answer is B: Administer an antiemetic as prescribed. Administering an antiemetic helps alleviate nausea and vomiting, providing relief to the patient. This action is based on evidence-based practice and helps improve the patient's comfort and well-being. Offering clear fluids immediately (choice A) may exacerbate nausea. Waiting for the nausea to subside on its own (choice C) may prolong the patient's discomfort. Assessing vital signs (choice D) is important but may not directly address the immediate symptom of nausea.

Correct Answer: B

Rationale: The correct answer is B: Hypothyroidism. In this case, the patient's symptoms of fatigue, weight gain, cold intolerance, dry skin, and slow heart rate are indicative of hypothyroidism. The thyroid gland is underactive, leading to decreased production of thyroid hormones, which regulate metabolism. These symptoms align with the typical clinical presentation of hypothyroidism. Other choices are incorrect because hyperthyroidism (choice A) would present with symptoms like weight loss, heat intolerance, and a fast heart rate. Cushing's syndrome (choice C) and Addison's disease (choice D) are both conditions related to the adrenal glands and would have different symptom presentations compared to what is described in the case scenario.

Correct Answer: A

Rationale: The correct answer is A: Limiting sodium intake. This is crucial for a patient with hypertension as excess sodium can lead to increased blood pressure. Sodium intake should be limited to lower the risk of cardiovascular complications. B: Increasing potassium intake is beneficial, but not as critical as limiting sodium for hypertension management. C: Increasing fluid intake may or may not be necessary depending on the patient's condition, but it is not as crucial as limiting sodium for hypertension management. D: Consuming more caffeine can actually elevate blood pressure, so it is not recommended for patients with hypertension.