health assessment in nursing test bank

Correct Answer: C

Rationale: The correct answer is C because determining if the patient can afford her medications is crucial in managing her diabetes effectively. Financial constraints can significantly impact a patient's ability to adhere to treatment, leading to poor health outcomes. By addressing affordability, the nurse can ensure the patient can access and comply with the prescribed medications. A, finding out why the patient is not compliant, is not the priority at this stage as addressing affordability comes first. B, reinforcing health teaching related to diet and exercise, is important but secondary to ensuring access to medications. D, sending the patient to the diabetic clinic for follow-up, is not as critical as addressing immediate financial concerns.

Correct Answer: B

Rationale: The correct answer is B: Respiratory failure. Asthma is a chronic respiratory condition that can lead to respiratory failure if not managed properly. The nurse should monitor for signs of worsening asthma symptoms such as increased respiratory rate, accessory muscle use, and decreased oxygen saturation. Pneumonia (A) is a possible complication but is not directly related to asthma. Anemia (C) and Hyperglycemia (D) are not typically associated with asthma and would not be the primary complications to monitor for in this case.

Correct Answer: D

Rationale: The correct answer is D: Papule. A papule is a solid, elevated lesion that is less than 1 cm in diameter. It is circumscribed, meaning it has well-defined borders. Papules are often associated with skin conditions like acne or insect bites. A: Bulla is a large fluid-filled blister, not a solid lesion. B: Wheal is a raised, red area of skin that is typically transient and caused by an allergic reaction. C: Nodule is a solid, elevated lesion that is greater than 1 cm in diameter, not less than 1 cm.

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: A

Rationale: The correct answer is A: Cold, dry air. Asthma patients are often triggered by cold, dry air, which can cause airway constriction and worsen symptoms. Warm, humid air can actually help alleviate symptoms by keeping airways moist. Excessive physical activity can also trigger asthma, but it varies among individuals and can be managed with appropriate medication and monitoring. Choice D is incorrect as warm, humid air is not a trigger for asthma.