health assessment test bank

Correct Answer: B

Rationale: The correct answer is B because it demonstrates active listening and seeks clarification on the issue at hand. By asking the woman to explain what she means by "fits," the nurse can gain a better understanding of the child's behavior and provide appropriate support and guidance. This response shows empathy and a willingness to address the woman's concerns effectively. Choice A is incorrect because it does not address the woman's specific concerns or invite further discussion. Choice C is incorrect because it simply acknowledges the woman's feelings without delving deeper into the issue. Choice D is incorrect as it dismisses the woman's feelings and generalizes the behavior as typical for all 2-year-olds without addressing her individual situation.

Correct Answer: A

Rationale: Step 1: Lisinopril is an ACE inhibitor commonly prescribed post-myocardial infarction to reduce strain on the heart and prevent further damage. Step 2: ACE inhibitors like Lisinopril help lower blood pressure and improve heart function. Step 3: By reducing the workload on the heart, Lisinopril can help prevent complications post-MI. Step 4: Acetaminophen (B) is a pain reliever and does not address the cardiovascular issues post-MI. Step 5: Furosemide (C) and Hydrochlorothiazide (D) are diuretics typically used for managing fluid retention, not the primary focus after an MI. Summary: Lisinopril is the correct choice as it helps improve heart function and prevent complications post-MI, unlike the other options which do not directly address the cardiovascular issues associated with MI.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial in diabetic neuropathy to prevent complications such as infections and ulcers. By inspecting the feet daily, the patient can identify any injuries early and seek prompt treatment. Exercising (choice B) is important, but not the top priority. Taking pain medication (choice C) only addresses symptoms, not the root cause. Increasing protein intake (choice D) may be beneficial for healing, but foot inspection is more directly related to preventing complications in diabetic neuropathy.

Correct Answer: C

Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function. A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism. B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism. D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): Promoting activity is the most prioritized nursing intervention for a client with CHF. Activity helps improve cardiac function, decreases fluid accumulation, and enhances overall cardiovascular health. It also prevents complications like muscle weakness and deconditioning. It is crucial in managing CHF symptoms and improving the client's quality of life. Summary of Incorrect Choices: A: Administering diuretics helps in reducing fluid overload but does not address the underlying issue of improving cardiac function through physical activity. B: Limiting fluid intake is important, but promoting activity takes precedence as it directly impacts cardiac function and fluid accumulation. D: Maintaining fluid balance is necessary but is a broad concept that includes various interventions, with promoting activity being more focused and critical in CHF management.