health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the recommended initial medication for chest pain in a client with a history of myocardial infarction. It helps dilate blood vessels, improving blood flow to the heart, and reducing chest pain. Aspirin (choice B) is also usually given to reduce blood clot formation, but nitroglycerin is the priority for immediate relief. Morphine (choice C) may be used if nitroglycerin is ineffective, and beta blockers (choice D) are typically used for long-term management of heart conditions, not for immediate relief of chest pain.

Correct Answer: C

Rationale: The correct answer is C because the statement made by the nurse implies a power dynamic that can create dependency and inferiority in the patient, which is not conducive to a patient-centered approach. In a healthcare setting, it is important to empower patients to be active participants in their care decisions rather than being passive recipients. Encouraging patients to blindly follow orders without understanding or questioning can lead to poor outcomes and lack of patient engagement. Therefore, it is best to avoid making statements that reinforce hierarchical relationships and instead foster open communication and shared decision-making. The other choices are incorrect because: A: This choice focuses on bias, which is not the main issue at hand in this scenario. B: While healthcare team members are experts in their respective fields, the emphasis should be on collaborative decision-making rather than blind obedience. D: Using authority statements may be necessary in certain situations, but it does not address the potential harm of creating dependency and inferiority in the patient.

Correct Answer: C

Rationale: The correct answer is C. Stopping insulin once blood glucose is normal is incorrect as insulin is crucial for managing diabetes even when blood glucose levels are within the target range. Insulin helps regulate blood sugar levels consistently, and stopping it abruptly can lead to hyperglycemia. Choices A, B, and D are correct statements indicating good diabetes management practices. Monitoring blood glucose levels, exercising regularly, and following a balanced diet are essential for controlling blood sugar levels and overall health.

Correct Answer: A

Rationale: The correct answer is A: Inspect for visible pulsation. This is because an arteriovenous fistula for hemodialysis should have a visible pulsation, indicating proper blood flow. Palpating for thrill (B) and auscultating for bruit (C) are also common assessments for an arteriovenous fistula, but inspecting for visible pulsation is the most direct and reliable way to assess the patency of the fistula. Percussing for dullness (D) is not relevant in this context as it does not provide information about the vascular access site.

Correct Answer: B

Rationale: The correct answer is B because the mental health examination should be integrated into the health history interview. This allows for a comprehensive understanding of the patient's mental health status. Gathering mental health information during the health history interview is crucial as it provides insight into the patient's current mental state, past history, and potential risk factors. This integrated approach is efficient and effective in assessing the patient's mental health needs. A is incorrect because while family input can be valuable, it is not always the best or only resource for information about coping skills. C is incorrect as integrating the mental health examination into the health history interview should not necessarily take an enormous amount of extra time if done efficiently. D is incorrect as a complete mental health examination may not always be necessary to assess the patient's level of functioning; integrating mental health information into the health history interview can often provide sufficient insight.