jarvis health assessment test bank

Correct Answer: C

Rationale: The primary purpose of an abdominal binder after surgery is to increase circulation. An abdominal binder helps improve blood flow to the surgical site, which can aid in reducing swelling, promoting healing, and preventing complications such as blood clots. It provides gentle compression to support the abdominal muscles and tissues without restricting circulation. Choice A (Promote comfort) is incorrect because while an abdominal binder may provide some comfort by supporting the abdomen, its primary purpose is not solely for comfort. Choice B (Prevent infection) is incorrect because an abdominal binder does not directly prevent infection. Infection prevention is primarily achieved through proper wound care and infection control practices. Choice D (Provide wound care) is incorrect because an abdominal binder does not provide wound care. Wound care involves cleaning, dressing changes, and monitoring for signs of infection, which are separate from the purpose of an abdominal binder.

Correct Answer: B

Rationale: The correct answer is B: "Is there anything else you would like to mention?" This question allows the patient to share any additional information or concerns before concluding the interview. It shows empathy and ensures thorough communication. Choice A is not the best option as it may suggest the nurse is rushing or has overlooked something. Choice C is inappropriate as it lacks empathy and may make the patient feel rushed. Choice D is also incorrect as it shifts the focus to a different topic instead of allowing the patient to express any remaining issues or questions.

Correct Answer: C

Rationale: The correct answer is C. Patients with cirrhosis should limit protein intake to prevent hepatic encephalopathy. Statement C indicates a need for further education as it is incorrect. A is correct as alcohol worsens cirrhosis. B is correct to manage symptoms. D is correct to monitor for fluid retention.

Correct Answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. In chronic heart failure, fluid overload can lead to pulmonary congestion, causing shortness of breath. Weight gain is also a key sign of fluid retention. Increased urine output and hypotension (choice B) are more indicative of dehydration. Fatigue and dizziness (choice C) can be nonspecific symptoms and not directly related to fluid overload. Dry mouth and thirst (choice D) are symptoms of dehydration rather than fluid overload in chronic heart failure. Monitoring for shortness of breath and weight gain allows for early detection and intervention in managing fluid overload in patients with chronic heart failure.

Correct Answer: B

Rationale: The correct answer is B: Check the room temperature. This is important because extreme temperatures can affect the accuracy of bowel sound assessment. Cold temperatures can cause vasoconstriction, leading to decreased bowel sounds, while warm temperatures can lead to increased sounds due to increased blood flow. Choice A (Clean the stethoscope before use) is important for infection control but not directly related to ensuring accurate bowel sound assessment. Choice C (Place the stethoscope directly on the skin) is incorrect as bowel sounds are auscultated through clothing. Choice D (Use a hand sanitizer after use) is important for hand hygiene but not necessary before using the stethoscope for bowel sounds.