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: A

Rationale: The correct answer is A: Administering bronchodilators as prescribed. Rationale: 1. Bronchodilators help dilate the airways, improving airflow in COPD patients. 2. Priority is to address the underlying respiratory issue. 3. Bronchodilators are a standard treatment for managing COPD symptoms. 4. Improving airway patency is crucial in COPD exacerbations. Summary: - B: Encouraging avoidance of physical activity is incorrect as it can lead to deconditioning. - C: Providing supplemental oxygen is important but not the priority in this case. - D: Monitoring for acute kidney injury is unrelated to COPD management.

Correct Answer: D

Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.

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: B

Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.