health assessment in nursing test bank

Correct Answer: C

Rationale: Rationale for Correct Answer C: - As individuals age, it is normal to experience a slight decline in cognitive abilities, such as response time. - However, general knowledge and abilities are usually well-preserved in older adults. - It is expected that the 75-year-old patient may take a little longer to respond due to age-related changes but should not have a significant decline in general knowledge. Summary of Incorrect Choices: - Choice A is incorrect because it is unrealistic to expect no decrease in any abilities with age. - Choice B is incorrect because while remote memory may decline with age, it is not a universal expectation for all older adults. - Choice D is incorrect as it inaccurately attributes language loss and a decrease in general knowledge to all older adults.

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 because a health history aims to gather subjective information about a patient's past and current health. It helps in understanding the patient's health concerns, medical history, lifestyle factors, and other relevant information. By collecting this data, healthcare providers can make informed decisions regarding the patient's care. Option A is incorrect as the purpose is more than just interaction. Option B is incorrect as it focuses solely on biographical information. Option C is incorrect as it pertains to physical assessment findings, not subjective health information.

Correct Answer: B

Rationale: The correct answer is B: Agnosia. Agnosia is the inability to recognize or interpret sensory information, such as temperature or clothing. In this case, the woman's inability to differentiate between hot and cold and dress appropriately for the weather indicates a sensory processing issue, characteristic of agnosia. A: Mania is a mood disorder characterized by extreme excitement and impulsivity, not related to sensory perception issues. C: Dementia is a broad term for cognitive decline, which typically includes memory loss and impaired decision-making, but not necessarily sensory perception deficits. D: Amnestic disorder refers to memory impairment, not the inability to interpret sensory information.

Correct Answer: A

Rationale: The correct answer is A: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels. Monitoring for hyperglycemia is crucial to prevent complications like diabetic ketoacidosis. Hypoglycemia (B) is low blood sugar, dehydration (C) is not directly related to diabetes unless it causes hyperosmolar hyperglycemic state, and hypotension (D) is low blood pressure, which is not a common complication of diabetes. Regular monitoring for hyperglycemia helps in preventing diabetic complications.