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: C

Rationale: The correct answer is C: "Are you feeling so hopeless that you feel like hurting yourself now?" This response directly addresses the patient's suicidal ideation and assesses the immediate risk of harm. It shows the nurse's concern for the patient's safety and allows for further evaluation and intervention if necessary. Option A is incorrect because asking about owning a lethal weapon does not directly address the patient's current mental state and immediate risk of harm. Option B is incorrect as it focuses on external factors rather than the patient's internal feelings of hopelessness and suicidal thoughts. Option D is incorrect as it minimizes the seriousness of the patient's symptoms and may lead to overlooking the urgency of the situation.

Correct Answer: D

Rationale: Rationale: 1. Current health promotion activities are important to assess the patient's preventive measures. 2. At 87 years old, focusing on current habits can help identify areas for improvement. 3. Obstetrical history is irrelevant as the patient is postmenopausal. 4. Childhood illnesses are less relevant compared to current health status. 5. General health for the past 20 years may not reflect current health behaviors.

Correct Answer: C

Rationale: The correct answer is C, hypercapnia. In COPD, impaired lung function leads to inadequate oxygen exchange, causing increased carbon dioxide levels in the blood (hypercapnia). This can result in respiratory acidosis and further exacerbate respiratory distress. Monitoring for hypercapnia is crucial in COPD management to prevent respiratory failure. Incorrect choices: A: Pulmonary embolism - While patients with COPD are at increased risk for blood clots, pulmonary embolism is not a direct complication of COPD. B: Pneumothorax - Although individuals with COPD may develop pneumothorax due to weakened lung tissue, it is not a common complication. D: Asthma attack - Asthma and COPD are distinct conditions with different pathophysiology. Asthma attacks are not a typical complication of COPD.

Correct Answer: B

Rationale: The correct answer is B: Jaundice. In chronic liver disease, impaired liver function leads to the accumulation of bilirubin in the blood, causing jaundice. Jaundice is a common complication seen in patients with liver disease. Anemia (choice A) may occur in liver disease but is not as specific as jaundice. Hypertension (choice C) is not a direct complication of liver disease. Hypoglycemia (choice D) is more commonly associated with pancreatic disorders, not liver disease. Therefore, monitoring for jaundice is crucial in patients with chronic liver disease.