jarvis health assessment test bank

Correct Answer: C

Rationale: The correct answer is C, BMI indicates obesity (35). To calculate BMI, we use the formula BMI = (Weight in pounds / (Height in inches x Height in inches)) x 703. Plugging in the values (216 / (66 x 66)) x 703, we get a BMI of approximately 35. A BMI of 35 falls within the obesity category (BMI 30 or higher). Choice A is incorrect because a BMI of 35 is not within normal limits. Choice B is incorrect as a BMI of 27 would indicate overweight status, not obesity. Choice D is incorrect as the BMI calculated is higher than normal, not lower.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants are crucial in treating DVT as they prevent blood clots from getting larger and stop new clots from forming. They help reduce the risk of complications like pulmonary embolism. Administering analgesics (B) may help with pain but does not address the root cause. Diuretics (C) are used to treat conditions like fluid retention, not DVT. Applying a warm compress (D) can actually worsen DVT by promoting blood flow. Anticoagulants are the gold standard treatment for DVT.

Correct Answer: C

Rationale: The correct answer is C: Assessing for signs of infection. This is the priority because diabetic foot ulcers are at high risk for infection, which can lead to serious complications. By assessing for signs of infection such as redness, warmth, swelling, pus, or foul odor, the nurse can promptly identify and initiate appropriate treatment. Administering antibiotics (A) should be based on the assessment findings. Providing pain relief (B) is important but not the priority when infection is a concern. Encouraging weight-bearing activity (D) may worsen the ulcer and should be avoided initially.

Correct Answer: D

Rationale: The correct answer is D because it provides a thorough list of specific childhood illnesses and confirms the patient's denial of having had them. This approach ensures comprehensive documentation and accuracy. Choice A is vague and lacks specificity, potentially leading to misunderstandings. Choice B focuses on the patient's perception of their health rather than actual illnesses. Choice C mentions the patient's sister and measles, which is irrelevant to the patient's own medical history. Overall, choice D is the most accurate and relevant option for documenting the patient's childhood illnesses.

Correct Answer: B

Rationale: The correct answer is B: Administer thrombolytics. Thrombolytics help dissolve blood clots, which may be causing the stroke. Administering thrombolytics promptly can improve blood flow to the brain, potentially reducing the severity of the stroke and its effects, including difficulty speaking. Calling for help (A) is important, but administering thrombolytics should be a priority. Performing a CT scan (C) may help confirm the type of stroke but may delay immediate treatment. Administering bronchodilators (D) is not indicated for difficulty speaking related to stroke.