health assessment exam 1 test bank

Correct Answer: A

Rationale: The correct answer is A: intuition. Expert nurses develop intuition through years of experience, allowing them to recognize patterns in assessment data and act quickly without conscious labeling. This intuitive response is based on a deep understanding of situations and is often more efficient than consciously going through the nursing process. Clinical knowledge (C) is important but refers to theoretical understanding. The nursing process (B) involves systematic steps in patient care, not the automatic response seen in intuition. Diagnostic reasoning (D) involves a more deliberate thought process in identifying and treating health issues.

Correct Answer: A

Rationale: The correct answer is A: Lethargic. Lethargic is defined as a state of drowsiness or diminished alertness where the patient can be easily aroused by simple stimuli like calling their name, but they remain drowsy and may drift back to sleep. This patient's ability to be aroused by verbal stimuli and their drowsiness during conversation fits the description of lethargic. Explanation for other choices: B: Obtunded - Obtunded refers to a more severe level of decreased consciousness where the patient is difficult to fully arouse and may have limited interactions with the nurse. C: Stuporous - Stuporous indicates an even deeper state of unconsciousness where the patient requires significant stimulation to be aroused and has minimal responsiveness. D: Semialert - Semialert would describe a patient who is more responsive than lethargic, showing better awareness of their surroundings and able to maintain a conversation more effectively.

Correct Answer: C

Rationale: The correct answer is C. This statement indicates a misunderstanding because stopping medication once blood pressure is normal can lead to a relapse of hypertension. Step 1: Medication management is crucial for long-term control of hypertension. Step 2: Stopping medication abruptly can cause blood pressure to rise again. Step 3: Regular monitoring, limiting sodium intake, and exercising are all important aspects of hypertension management. Summary: Choices A, B, and D demonstrate good understanding of hypertension management, while choice C shows a need for further education on the importance of continued medication use.

Correct Answer: C

Rationale: The correct answer is C, monitoring vital signs and fluid status, because it is crucial for assessing the patient's immediate post-operative condition and detecting any signs of complications like hemorrhage or shock. This step ensures early intervention if any issues arise, promoting patient safety and recovery. Administering pain medication (A) is important but not the top priority. Encouraging early ambulation (B) and providing wound care (D) are also essential but come after ensuring the patient's vital signs and fluid status are stable.

Correct Answer: A

Rationale: The correct answer is A: Jaundice. In chronic liver disease, impaired liver function can result in the accumulation of bilirubin leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial in assessing the progression of liver disease. B: Hypoglycemia is not a common complication of chronic liver disease. Liver plays a role in glycogen storage and glucose production, so hypoglycemia is less likely. C: Hyperglycemia is more commonly associated with conditions like diabetes rather than chronic liver disease. The liver's role in glucose regulation may be impaired, but hyperglycemia is not a typical complication. D: Anemia is not directly related to liver disease, although it may occur as a secondary complication due to factors like decreased production of certain blood components. Monitoring for anemia is important, but jaundice is a more specific complication of chronic liver disease.