health assessment exam 2 test bank

Correct Answer: B

Rationale: The correct answer is B: 1.5 m. This distance is known as the personal distance in communication, where most interviews take place. Personal distance allows for a comfortable level of interaction without invading personal space. Choice A (1 m) is too close and may make the patient uncomfortable. Choice C (2 m) is too far for an intimate interview setting. Choice D (3 m) is too distant and may lead to a lack of connection and understanding during the interview. Overall, B is the best choice for a nurse-patient interview to ensure a respectful and effective conversation.

Correct Answer: A

Rationale: The correct answer is A. Encouraging early ambulation and use of compression stockings is crucial post-abdominal surgery to prevent complications like deep vein thrombosis and pneumonia. Ambulation helps prevent blood clots and promotes lung expansion. Compression stockings aid in preventing blood pooling in the legs. Administering pain medication regularly (B) is important but not the priority. Monitoring for infection (C) is essential but not the priority immediately post-op. Providing nutritional support and hydration (D) is important but not as critical as preventing immediate complications.

Correct Answer: B

Rationale: The correct answer is B: Bleeding or perforation. After a colonoscopy, the patient is at risk for bleeding or perforation which are serious complications requiring immediate attention. Monitoring for signs such as abdominal pain, rectal bleeding, or signs of peritonitis is crucial. Choice A is not a priority unless the patient shows signs of shock. Choice C is a common post-procedure issue but not a priority complication. Choice D, pain at the insertion site, is expected and can be managed with analgesics.

Correct Answer: C

Rationale: The correct answer is C because stopping medication without consulting a healthcare provider can lead to uncontrolled hypertension. Choice A shows understanding of monitoring blood pressure, B demonstrates adherence to medication regimen, and D indicates awareness of dietary management. Choice C is incorrect because abruptly stopping medication can have serious health consequences, making further education necessary.

Correct Answer: D

Rationale: The correct answer is D: Increasing caffeine consumption. Caffeine can potentially raise blood pressure in individuals with hypertension. The rationale is that caffeine is a stimulant that can lead to temporary spikes in blood pressure. This can be harmful for patients with a history of hypertension as it can exacerbate their condition. A: Increasing potassium intake is generally recommended for individuals with hypertension as it can help lower blood pressure. B: Consuming more fruits and vegetables is also beneficial for hypertension due to their high fiber and nutrient content. C: Limiting sodium intake is crucial for managing hypertension as high sodium levels can lead to increased blood pressure. In summary, increasing caffeine consumption is the correct answer to avoid for patients with hypertension, as it can potentially worsen their condition by raising blood pressure.