advanced health assessment test bank

Correct Answer: B

Rationale: The correct answer is B because the woman's nonverbal cues (looking nervously at her hands, sighing audibly) indicate potential anxiety or stress. The nurse should acknowledge these cues and explore her feelings further to provide appropriate support. Option A is incorrect as it does not address the woman's nonverbal cues. Option C is incorrect as it assumes the woman is not genuinely excited about the pregnancy. Option D is incorrect as it overlooks the woman's nonverbal cues and does not address her potential emotional needs.

Correct Answer: D

Rationale: The correct answer is D: "What cultural or spiritual beliefs are important to you?" This question allows the nurse to understand the elder's values and beliefs, guiding care. A: Assumes a specific faith. B: Stereotypes the elder. C: Focuses on frequency of medical visits, not beliefs.

Correct Answer: D

Rationale: The correct answer is D: Rotate injection sites to prevent lipodystrophy. Rotating injection sites helps prevent the development of lipodystrophy, a condition characterized by the loss of fat tissue at the injection site. This is important for maintaining consistent insulin absorption and reducing the risk of injection site complications. A: Storing insulin at room temperature is generally recommended, but it is not the most critical action for insulin administration. B: Using insulin immediately after drawing it up is not necessary for all types of insulin and may not be feasible in all situations. C: Injecting insulin into the same spot can lead to tissue damage and inconsistent insulin absorption, so it should be avoided.

Correct Answer: C

Rationale: The correct answer is C because it indicates that the information was provided directly by the patient and is based on their perception or feeling. Subjective data is based on the patient's experiences and cannot be observed or measured by others. Choices A, B, and D are all objective data as they can be observed or measured by healthcare providers. Choice A describes a visible characteristic of the skin, choice B indicates absence of observable lesions, and choice D reports an observed lesion on a specific location of the skin. Therefore, choice C is the only option that reflects subjective data about the patient's skin.

Correct Answer: C

Rationale: The correct answer is C: Abnormal laboratory values. Second-level priority problems are those that are important to the patient's health but may not be life-threatening. Abnormal laboratory values fall into this category as they indicate an underlying health issue that needs attention. Low self-esteem (A) and lack of knowledge (B) are typically considered third-level priority problems, as they do not pose an immediate threat to the patient's health. Severely abnormal vital signs (D) are first-level priority problems, as they indicate an acute and potentially life-threatening situation that requires immediate intervention. Therefore, the correct answer is C as it aligns with the definition of second-level priority problems.