health assessment test bank jarvis

Correct Answer: D

Rationale: The correct answer is D because the patient demonstrates orientation to person (knows their name), place (knows they are at the hospital in Victoria), and time (knows it is February of a new year � 2009). This indicates intact orientation across all three domains. Choice A is incorrect as the patient is unsure of their location and the year. Choice B is incorrect as the patient is confused about the date. Choice C is incorrect as the patient is uncertain about the date and only guesses their location.

Correct Answer: D

Rationale: The correct answer is D because it focuses on assessing the impact of the pain on the woman's daily activities, which is crucial in understanding the severity and functional limitations caused by the pain. This helps in planning appropriate interventions and evaluating the effectiveness of treatment. Choice A is incorrect as it shifts the focus to the family's reaction rather than the woman's pain. Choice B is incorrect as it assumes a diagnosis without proper assessment and may minimize the woman's experience. Choice C is incorrect as it redirects the conversation to the nurse's experience, which is not helpful in addressing the woman's pain and needs.

Correct Answer: D

Rationale: The correct answer is D: Administer morphine. The rationale is that vomiting after surgery can be a side effect of pain medication such as morphine. By administering morphine, the pain is reduced, which can help alleviate the vomiting. This intervention targets the root cause of the vomiting. Other choices are incorrect because: A: Administering antiemetics may help with nausea but does not address the underlying cause of vomiting. B: Placing the client in a supine position may worsen vomiting due to increased abdominal pressure. C: Encouraging deep breathing may help with relaxation but does not directly address the vomiting caused by pain.

Correct Answer: A

Rationale: Administering oxygen is the most important action for a client with respiratory distress because it helps improve oxygen levels in the blood and supports breathing. Oxygen therapy can prevent hypoxia and reduce respiratory workload. Corticosteroids, bronchodilators, and analgesics may be beneficial in specific situations, but they are not the primary intervention for respiratory distress. Corticosteroids reduce inflammation, bronchodilators help open airways, and analgesics provide pain relief but do not directly address the underlying issue of inadequate oxygenation. Administering oxygen should always be the first priority in managing respiratory distress.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. The nurse should address the client's immediate symptom of severe headache to provide comfort and assess the severity of the condition. Pain relief can help decrease anxiety and prevent complications. Monitoring vital signs (B) is important but treating the symptom should take priority. Monitoring ECG (C) is not necessary for a headache presentation. Administering insulin (D) is not indicated for a client presenting with a severe headache.