health assessment test bank

Correct Answer: D

Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.

Correct Answer: B

Rationale: The correct answer is B because asking someone who knows the patient well can provide valuable insight into the meaning behind the verbal and nonverbal communication discrepancy. This helps in understanding the context and potential reasons for the inconsistency. Option A is incorrect as ignoring nonverbal behaviors can lead to missing important cues. Option C of interpreting messages as an 'average' may oversimplify the complexity of communication. Option D is incorrect as while nonverbal behaviors can provide valuable information, solely focusing on them may not give a complete understanding of the situation.

Correct Answer: D

Rationale: The correct answer is D. Hypertension can lead to various complications affecting the heart, kidneys, and brain. Monitoring for heart failure is crucial due to the increased workload on the heart. Chronic kidney disease is a common complication of hypertension, as the kidneys are sensitive to changes in blood pressure. Stroke is another significant risk due to the potential damage to blood vessels in the brain. Therefore, monitoring for all these complications is essential in managing a patient with hypertension. Other choices are incorrect as they do not encompass all possible complications of hypertension.

Correct Answer: C

Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice B) and introspective (choice D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the first intervention for shock as it helps improve oxygenation to vital organs. Lack of oxygen can worsen shock. Administering IV fluids (choice B) could be the second step to improve perfusion. Monitoring respiratory rate (choice C) is important but not the first intervention. Administering pain medication (choice D) is not a priority in managing shock.