health assessment in nursing test bank

Correct Answer: C

Rationale: The correct answer is C: A complete health database because of the nurse's primary responsibility for monitoring the patient's health. In this initial home visit, the nurse needs to gather comprehensive information about the patient's medical history, current health status, medications, allergies, and lifestyle factors to establish a baseline for ongoing care. This complete health database will help the nurse make informed decisions and provide personalized care. Choice A (follow-up database) is incorrect as it is used to evaluate changes over time, not for the initial assessment. Choice B (episodic database) is incorrect because the patient's chronic medical problems require a more comprehensive approach. Choice D (emergency database) is incorrect as it is used for urgent situations, not for routine assessments.

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In CKD, kidneys struggle to excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac arrhythmias. Hypokalemia (B) is unlikely in CKD due to impaired potassium excretion. Hyperglycemia (C) is more commonly associated with diabetes rather than CKD. Hypercalcemia (D) is not a typical complication of CKD; instead, patients with CKD often experience low calcium levels.

Correct Answer: A

Rationale: The correct answer is A: Document the findings on the patient's record. This is the appropriate action because documenting the unfamiliar sound ensures that the information is accurately recorded for future reference. Waiting 10 minutes (B) may not address the issue, as the sound could still be present. Asking another nurse to double-check (C) may lead to subjective interpretations. Asking the patient to take deep breaths (D) may not be relevant to identifying the unfamiliar sound. Recording the finding is crucial for tracking changes in the patient's condition and communicating with other healthcare professionals.

Correct Answer: D

Rationale: The correct answer is D: Open-ended question. This verbal skill allows the patient to provide detailed information and express their feelings freely. By asking the patient to talk more about their shortness of breath, the nurse encourages a comprehensive response. Reflection (A) involves paraphrasing the patient's words, not eliciting more information. Facilitation (B) involves encouraging the patient to continue but does not necessarily prompt open-ended responses. Direct question (C) typically elicits a specific answer and limits the patient's response.

Correct Answer: C

Rationale: The correct answer is C: 55-64 years. This age group has exceeded that of people aged 15-24 due to factors like increased life expectancy, lower birth rates, and the aging baby boomer population. This demographic shift impacts workforce, healthcare, and social services. Choice A is incorrect as it represents the youngest age group. Choice B is incorrect as it falls within the working-age group. Choice D is incorrect as it represents the elderly population, which is still lower than the 55-64 age group in this context.