health assessment test bank jarvis

Correct Answer: A

Rationale: The correct answer is A: Elevate the affected leg. This is the first action because elevating the leg helps reduce swelling and improve blood flow, reducing the risk of complications from the DVT. It also helps alleviate pain. Choice B: Applying compression stockings can be helpful in preventing DVT, but it is not the first action to take once it has developed. Choice C: Providing leg elevation is similar to choice A, but it lacks the specificity of elevating the affected leg to address the DVT directly. Choice D: Administering compression therapy may be necessary, but it is not the initial action to take when a client develops a DVT.

Correct Answer: C

Rationale: The correct answer is C: Swelling in the legs and shortness of breath. In heart failure, the heart is unable to pump effectively, leading to fluid accumulation in the body. Swelling in the legs (edema) is a classic sign of fluid overload as the fluid pools in the lower extremities. Shortness of breath occurs due to fluid accumulating in the lungs, causing difficulty in breathing. Weight loss and increased appetite (A) are not typical signs of fluid overload. Increased urine output and dehydration (B) are more indicative of fluid deficit. Nausea and vomiting (D) can occur in various conditions but are not specific to fluid overload in heart failure.

Correct Answer: D

Rationale: The correct answer is D because the patient demonstrates orientation to person (knows their name), place (knows they are at the hospital in Victoria), and time (knows it is February of a new year � 2009). This indicates intact orientation across all three domains. Choice A is incorrect as the patient is unsure of their location and the year. Choice B is incorrect as the patient is confused about the date. Choice C is incorrect as the patient is uncertain about the date and only guesses their location.

Correct Answer: B

Rationale: The correct answer is B: Asthma. Wheezing is a high-pitched whistling sound heard during expiration caused by narrowed airways in conditions like asthma. Pneumonia (A) typically presents with crackles, not wheezes. Pulmonary embolism (C) may cause sudden chest pain and shortness of breath but not wheezing. Pleural effusion (D) results in decreased breath sounds, not wheezes.

Correct Answer: A

Rationale: Administering oxygen is the most important action for a client with respiratory distress because it helps improve oxygen levels in the blood and supports breathing. Oxygen therapy can prevent hypoxia and reduce respiratory workload. Corticosteroids, bronchodilators, and analgesics may be beneficial in specific situations, but they are not the primary intervention for respiratory distress. Corticosteroids reduce inflammation, bronchodilators help open airways, and analgesics provide pain relief but do not directly address the underlying issue of inadequate oxygenation. Administering oxygen should always be the first priority in managing respiratory distress.