jarvis health assessment test bank pdf reddit

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. Dehydration and hypotension indicate fluid loss, which can lead to organ damage and shock. Administering IV fluids helps restore blood volume and improve blood pressure. Monitoring blood pressure (B) is important but addressing the underlying issue of fluid loss is crucial. Administering antihypertensive medications (C) would further lower blood pressure, worsening hypotension. Administering diuretics (D) would exacerbate fluid loss, worsening dehydration and hypotension.

Correct Answer: B

Rationale: The correct answer is B: Place the client in a supine position. This is the first step when administering Heparin to prevent bleeding or bruising at the injection site. Placing the client in a supine position helps reduce the risk of injury and promotes optimal absorption. Administering antipyretics (Choice A) is not the first step in administering Heparin. Administering insulin (Choice C) is unrelated to Heparin administration. Monitoring vital signs (Choice D) is important but typically done after the initial step of positioning the client correctly.

Correct Answer: A

Rationale: The correct answer is A: Place the client in a safe environment. This is the primary intervention for a client with a history of falls to prevent further injury. By ensuring the environment is safe, the risk of falls and subsequent injuries is minimized. Choice B, assessing the client's functional status, is important but not the primary intervention. Choice C, encouraging the client to rest, may not address the underlying issue of fall risk. Choice D, encouraging the client to ambulate, may increase the risk of falls for someone with a history of falls. It is crucial to prioritize safety by modifying the environment to prevent falls.

Correct Answer: A

Rationale: The correct answer is A because an auditory hallucination involves hearing something that is not actually present. In this scenario, the man is hearing his dead wife talking to him, which is a perception without an external auditory stimulus. This illustrates an auditory hallucination. Choice B is incorrect as it describes a visual hallucination, seeing the doorbell indicator light up and hearing the bell ring. Choice C is also incorrect as it describes a visual misperception, seeing a man in the closet that turns out to be a dry cleaning bag. Choice D is incorrect as it describes a misinterpretation of a visual stimulus, mistaking a blanket for a dog.

Correct Answer: C

Rationale: The correct answer is C: Monitor for transfusion reactions. When a client receiving a blood transfusion develops chills, it may indicate a transfusion reaction, such as a febrile non-hemolytic reaction. The nurse's first priority is to monitor the client closely for other signs of a reaction, such as fever, rash, or shortness of breath. Stopping the transfusion may be necessary, but monitoring for reactions is crucial to identify and manage any adverse effects promptly. Vital signs should be monitored as part of assessing for reactions. Performing a lumbar puncture is not indicated in this situation and is unrelated to managing a transfusion reaction.