health assessment test bank jarvis

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.

Correct Answer: D

Rationale: The correct answer is D: all of the above. Alcohol use can impair judgment leading to risky sexual behaviors. Certain sexual practices like unprotected sex or having multiple partners increase STD risk. Oral contraception does not protect against STDs. Therefore, all factors (A, B, C) collectively increase the risk of STDs.

Correct Answer: C

Rationale: The correct answer is C: Placing the client on their back. This is the priority because it helps optimize the client's breathing mechanics by maximizing lung expansion. By positioning the client on their back, it allows for better oxygenation and ventilation. Administering oxygen (A) and albuterol (B) can be important interventions but positioning comes first. Placing the client on their back also helps prevent aspiration and facilitates airway clearance. Encouraging deep breathing (D) is beneficial, but if the client is in respiratory distress, ensuring proper positioning takes precedence over deep breathing exercises.

Correct Answer: C

Rationale: The correct answer is C: "Never did too good in school." This statement should be explored further during an interview because it can provide insights into the patient's educational background, potential learning difficulties, or past experiences that may impact their health literacy or understanding of medical information. Understanding the patient's educational history can help the nurse tailor communication and education strategies effectively. A: "Sleeps like a baby" is not as critical for further exploration as it pertains to the patient's sleep quality. B: "Has no health problems" is important information but does not require immediate further exploration. D: "Is currently not taking any medication" is important for medication reconciliation but does not warrant immediate further exploration in this context.

Correct Answer: C

Rationale: The correct answer is C: Jaundice. In chronic liver disease, the liver's ability to process bilirubin is impaired, leading to jaundice. This is characterized by a yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates liver dysfunction. Hypoglycemia (A) is not a typical complication of chronic liver disease. Hyperkalemia (B) is more commonly associated with kidney dysfunction. Anemia (D) can occur in liver disease but is not as specific a complication as jaundice. Therefore, monitoring for jaundice in a patient with chronic liver disease is essential for early detection and management of liver dysfunction.