health assessment test bank jarvis

Correct Answer: A

Rationale: The correct answer is A: Open the airway. This is the first action because in respiratory distress, ensuring a clear airway is crucial for adequate oxygenation. Opening the airway helps facilitate breathing and prevents further complications. Administering oxygen (choice B) can be done after ensuring the airway is clear. Administering medication (choice C) and pain relief (choice D) are not the initial priority in managing respiratory distress.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.

Correct Answer: A

Rationale: The correct answer is A because asking "Why haven't you taken your insulin?" may put the patient on the defensive. This question can come across as accusatory or judgmental, potentially making the patient feel guilty or defensive. It may hinder open communication and lead to a breakdown in the nurse-patient relationship. Explanation of other choices: B: While the question may be an attempt to gather information, it lacks sensitivity and may not promote open dialogue. C: Involving the patient's wife without the patient's consent may breach confidentiality and undermine the patient's autonomy. D: While asking the question may reveal reasons for the behavior, it is not the best approach as it can create a barrier to effective communication.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This intervention is crucial for a client with an obstructed airway as it helps maintain oxygenation while efforts are made to clear the obstruction. Oxygen administration ensures the client receives adequate oxygen supply to prevent hypoxia and further complications. Monitoring respiratory rate (B) is important but not the priority when airway obstruction is present. Applying a cold compress (C) or administering corticosteroids (D) are not appropriate interventions for an obstructed airway and do not address the immediate need for adequate oxygenation.

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.