jarvis physical examination and health assessment 9th edition test bank

Correct Answer: B

Rationale: The correct answer is B, Blood pressure. Dizziness, blurred vision, and nausea can be symptoms of hypotension or hypertension. Assessing the patient's blood pressure first is crucial to determine if the symptoms are related to blood pressure fluctuations. Electrolyte levels (A) and blood glucose levels (C) may be assessed later but do not address the immediate concern. Temperature and respiratory rate (D) are important assessments but are not the priority in this scenario where cardiovascular status needs to be evaluated first.

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: B

Rationale: The correct answer is B: Encouraging early ambulation to prevent complications. Early ambulation after abdominal surgery helps prevent postoperative complications like deep vein thrombosis and pneumonia. It promotes circulation, aids in bowel function, and reduces the risk of atelectasis. Encouraging the patient to move also helps with pain management and overall recovery. Choice A: Administering antiemetics as needed. While addressing nausea and vomiting is important, it is not the top priority in this case. Choice C: Providing wound care and dressing changes. Wound care is crucial, but ensuring early ambulation takes precedence to prevent complications. Choice D: Monitoring for signs of infection. While monitoring for infection is essential, promoting early ambulation is a proactive measure to prevent various complications and enhance recovery.

Correct Answer: D

Rationale: The correct answer is D because shortness of breath and respiratory distress indicate a potentially life-threatening emergency requiring immediate intervention. This problem falls under the first-level priority as it addresses airway, breathing, and circulation, which are essential for survival. Choices A, B, and C are not first-level priorities as they do not pose an immediate threat to the patient's life or require urgent intervention. Postoperative pain, diabetes teaching, and a small foot laceration are important but can be addressed at a later time without immediate harm to the patient.

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.