health assessment test bank jarvis

Correct Answer: B

Rationale: The correct answer is B: Reorient the client. Reorientation helps the confused client regain awareness of their surroundings, time, and situation post-operatively. It can improve their cognition and reduce anxiety. Notifying the healthcare provider (A) may be necessary but not the primary concern. Increasing circulation (C) is important but not the first step for a confused post-op client. Assessing pain (D) is important but addressing confusion takes precedence.

Correct Answer: B

Rationale: The correct answer is B because the nurse needs more information to assess the situation effectively. By asking the patient more about the effects of the herbs, the nurse can gather crucial details about the patient's condition and the potential impact of the herbs on her health. This will help the nurse make an informed decision on the appropriate course of action. Choice A is incorrect because jumping to conclusions without gathering more information can be detrimental to the patient's care. Choice C is incorrect as sending the herbs for analysis may not provide immediate insights into the patient's condition. Choice D is incorrect as the focus should be on directly obtaining information from the patient rather than involving a third party.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the first priority because it helps prevent further injury to the spinal cord. By immobilizing the spine, the nurse ensures that any movement doesn't worsen the existing injury. Placing the client in a supine position (B) can be done after immobilization. Administering analgesics (C) should not be done before assessing the extent of the injury. Assessing the airway (D) is important but should come after immobilizing the spine to prevent any unnecessary movement.

Correct Answer: C

Rationale: The correct answer is C because monitoring vital signs and fluid status is crucial in managing chronic heart failure. This intervention helps in assessing the patient's condition, detecting any signs of deterioration, and ensuring appropriate fluid balance. Administering diuretics (A) may be necessary but should be based on the patient's fluid status. Encouraging rest (B) is important, but monitoring vital signs takes precedence. Teaching about dietary changes (D) is essential, but ensuring the patient's immediate stability through monitoring is the priority.

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In chronic kidney disease, the kidneys are unable to effectively excrete potassium, leading to elevated levels in the blood. This can result in life-threatening cardiac arrhythmias. Monitoring for hyperkalemia is crucial in managing patients with kidney disease. Other choices are incorrect because: B: Hypoglycemia is not typically associated with chronic kidney disease. C: Hypotension may occur in kidney disease but is not directly related to decreased renal function. D: Hypercalcemia is not a common complication of decreased renal function; in fact, kidney disease can lead to low levels of calcium.