health assessment exam 1 test bank

Correct Answer: C

Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Post-operative hip replacement patients are at high risk for DVT due to immobility and surgical trauma. The nurse should monitor for signs such as swelling, redness, and pain in the affected leg. DVT can lead to serious complications like pulmonary embolism if not detected early. Choices A, C, and D are incorrect because while pneumonia, wound infection, and hypoglycemia are also potential post-operative complications, they are not as directly associated with hip replacement surgery as DVT.

Correct Answer: B

Rationale: The correct answer is B: Assessment. The first step in the nursing process is to assess the patient's condition to gather data and information. In this case, assessing the patient's symptoms, vital signs, and history will help the nurse identify signs of pneumonia and determine the appropriate interventions. Diagnosis (A) comes after assessment, as it involves analyzing the data collected. Implementation (C) and Evaluation (D) are subsequent steps in the nursing process after assessment and diagnosis have been completed. Assessment is crucial for developing an effective care plan and ensuring the best possible outcomes for the patient.

Correct Answer: C

Rationale: The correct answer is C: Patient's level of consciousness. Assessing the patient's level of consciousness is crucial in a neurological assessment as it provides immediate information on the overall function of the brain. Changes in consciousness can indicate serious neurological issues such as head injuries or stroke. It is essential to prioritize assessing consciousness first to determine the urgency of the situation. Assessing reflexes (A), cranial nerve function (B), and pupil response (D) are also important in a neurological assessment but come after assessing the patient's level of consciousness, as they provide more specific and detailed information about the neurological status.

Correct Answer: B

Rationale: The correct answer is B because ethnicity is defined by shared heritage, culture, language, or religion. This definition encompasses the key components that make up an individual's ethnic identity. Choice A is incorrect because while political forces may influence ethnicity, it does not define the concept itself. Choice C is incorrect as ethnicity is not necessarily related to belief in a higher power. Choice D is incorrect as ethnicity is not solely a learned behavior but also includes innate aspects like heritage.