health assessment test bank jarvis

Correct Answer: D

Rationale: The correct answer is D: Head to toe. The head-to-toe assessment is efficient because it follows a systematic approach starting from the head and progressing downward, ensuring that all body parts are assessed while maintaining the patient's modesty. This approach allows the nurse to gather comprehensive data without compromising the patient's privacy. A: Body systems - While assessing by body systems is important, it may not provide the same level of modesty as the head-to-toe approach. B: Functional - Assessing by function focuses on specific body functions rather than a comprehensive assessment of all body systems. It may not address all aspects of the patient's health. C: Focused - A focused assessment targets specific health issues and may not cover all body systems comprehensively, potentially missing important findings.

Correct Answer: D

Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.

Correct Answer: D

Rationale: Rationale: 1. Altered family processes impact an infant's body image due to the emotional response and support provided by family members. 2. Positive family dynamics can help the infant cope with the diagnosis and build self-esteem. 3. Conversely, negative family processes may lead to feelings of inadequacy and affect body image. 4. Immobility, altered growth, and hemarthrosis are physical factors but do not directly influence body image. Summary: Altered family processes have the most significant impact on an infant's body image as they shape emotional support and self-perception. Immobility, altered growth, and hemarthrosis are important considerations but are not as directly related to body image in this context.

Correct Answer: B

Rationale: The correct answer is B: Initiate a stroke protocol. This is the most appropriate response because time is critical in treating a stroke. By initiating a stroke protocol, the nurse ensures that the client receives prompt and appropriate care, including timely evaluation, imaging studies, and potential interventions such as administering clot-busting medication. Performing a neurological assessment (A) is important but may delay crucial interventions. Positioning the client on their side (C) is essential for airway protection but should not be the initial priority. Starting a CT scan (D) is important for diagnosis but should not delay the initiation of the stroke protocol, which includes obtaining imaging studies.

Correct Answer: D

Rationale: The correct answer is D because stopping medication once blood pressure returns to normal can lead to a relapse of hypertension. Step 1: Educate the patient that hypertension is a chronic condition requiring long-term management. Step 2: Explain the importance of continuing medication even when blood pressure is controlled. Step 3: Emphasize the risks of stopping medication abruptly. Other choices are incorrect because they promote positive behaviors for hypertension management: A: Monitoring blood pressure is essential. B: Taking medication consistently is crucial. C: Avoiding high-sodium foods helps control blood pressure.