health assessment test bank jarvis

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: B

Rationale: Step 1: Stroke patients are at increased risk for DVT due to immobility. Step 2: Monitoring for DVT signs is crucial for early detection and prevention. Step 3: Prompt intervention can prevent life-threatening complications. Step 4: Encouraging mobility (Choice A) is important but not the priority. Step 5: Administering antihypertensive meds (Choice C) may be necessary but not the priority. Step 6: Providing psychological support (Choice D) is important but not as critical as DVT monitoring.

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: A

Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to relax and open up the airways, which can alleviate shortness of breath and chest tightness in conditions like asthma or COPD. Administering oxygen (choice B) can help if the client is hypoxic, but it does not directly address the underlying airway constriction. Applying a cold compress (choice C) may provide some comfort but will not address the respiratory distress. Administering IV antibiotics (choice D) is not indicated for shortness of breath and chest tightness unless there is an underlying bacterial infection.

Correct Answer: D

Rationale: The correct answer is D because it focuses on assessing the impact of the pain on the woman's daily activities, which is crucial in understanding the severity and functional limitations caused by the pain. This helps in planning appropriate interventions and evaluating the effectiveness of treatment. Choice A is incorrect as it shifts the focus to the family's reaction rather than the woman's pain. Choice B is incorrect as it assumes a diagnosis without proper assessment and may minimize the woman's experience. Choice C is incorrect as it redirects the conversation to the nurse's experience, which is not helpful in addressing the woman's pain and needs.