health assessment test bank jarvis

Correct Answer: B

Rationale: The correct answer is B: Urine output monitoring. This method is the best for assessing fluid balance in a client with kidney disease because the kidneys play a key role in regulating fluid balance by controlling urine production. Monitoring urine output provides direct insight into the body's fluid status and kidney function. Daily weight measurements (A) can be influenced by factors other than fluid balance. Electrolyte panel monitoring (C) assesses electrolyte levels, not fluid balance specifically. Monitoring vital signs (D) can give clues to fluid imbalance but is not as direct or specific as urine output monitoring.

Correct Answer: B

Rationale: The correct answer is B: Pulmonary edema. In heart failure, the heart is unable to pump effectively, leading to fluid buildup in the lungs causing pulmonary edema. This can result in symptoms such as shortness of breath, coughing, and wheezing. Monitoring for pulmonary edema is crucial in heart failure management to prevent respiratory distress and worsening heart function. Rationale: A: Hypoglycemia - While patients with heart failure may be at risk for metabolic abnormalities, hypoglycemia is not a common complication directly related to heart failure. C: Anemia - Anemia can occur in heart failure due to reduced oxygen-carrying capacity of the blood, but it is not a direct complication that requires immediate monitoring like pulmonary edema. D: Hypertension - Heart failure is characterized by a reduced ability of the heart to pump blood effectively, leading to decreased cardiac output. Therefore, hypertension is not typically a complication seen in heart failure patients.

Correct Answer: D

Rationale: Correct Answer: D - Administering oxygen Rationale: 1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload. 2. Administering oxygen helps alleviate ischemia and prevents further damage. 3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being. Summary of other choices: A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction. B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation. C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Huntington's chorea. Huntington's chorea is a genetic disorder characterized by involuntary, writhing, and twisting movements of the face and limbs, known as chorea. This is due to degeneration of certain brain cells. Epilepsy (A) involves seizures, not specific movements. Parkinson's (B) is characterized by tremors and rigidity, not chorea. Multiple sclerosis (C) affects the central nervous system, causing a variety of symptoms, but not typically chorea.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. This is the most important nursing intervention for a client with severe dehydration because IV fluids provide rapid rehydration and help restore electrolyte balance efficiently. Monitoring vital signs (choice B) is important but not as crucial as providing immediate fluid replacement. Providing oral rehydration (choice C) may not be effective for severe dehydration as the client may have difficulty absorbing fluids orally. Administering oxygen (choice D) is not directly related to treating dehydration, so it is not the most important intervention in this scenario.