jarvis health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. The priority nursing action for a client with severe dehydration is to restore fluid volume to maintain vital organ function. Administering IV fluids is crucial in rapidly replenishing lost fluids and electrolytes. Corticosteroids (choice B) are not indicated for dehydration. Re-administering IV fluids (choice C) is redundant. Administering analgesics (choice D) is not a priority in the management of severe dehydration.

Correct Answer: A

Rationale: The correct answer is A: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and vascular damage. Monitoring for DVT is crucial to prevent life-threatening complications like pulmonary embolism. Acute renal failure (A) is not directly related to stroke and is not a common complication. Pneumonia (C) may occur but is not the highest priority compared to DVT. Hypertension (D) is important to monitor but is not the priority in this case as DVT poses a more immediate risk to the patient's health.

Correct Answer: A

Rationale: The correct answer is A: Apply a sterile dressing. This is the most important intervention to prevent infection and protect the wound. Applying a sterile dressing helps maintain a clean environment, reduces the risk of contamination, and promotes wound healing. Administering fluids (B) may be necessary but is not the top priority. Administering IV antibiotics (C) may be required but is secondary to wound care. Monitoring for bleeding (D) is important but addressing the wound with a sterile dressing takes precedence to prevent infection.

Correct Answer: C

Rationale: The correct answer is C: Functional. Functional assessment focuses on roles and relationships of the client by evaluating how well they can perform daily activities and interact with others. This type of assessment provides valuable insights into a client's overall well-being and ability to function independently. Incorrect choices: A: Body systems - This type of assessment focuses on the physical structures and functions of the body, not on the client's roles and relationships. B: Head to toe - This refers to a comprehensive physical examination from head to toe, which does not specifically address the client's roles and relationships. D: Focused - This type of assessment targets a specific issue or concern, but it may not necessarily delve into the client's roles and relationships.