health assessment exam 1 test bank

Correct Answer: C

Rationale: The correct initial question to ask a patient with a positive tuberculin test is whether they have received bacille Calmette-Gu�rin (BCG) vaccine. This is because BCG vaccination can cause a false positive result on the tuberculin test due to cross-reactivity with the purified protein derivative (PPD) used in the test. Asking about recent hospitalization (A), homelessness (B), or recent travel out of the country (D) would not provide relevant information regarding the interpretation of the positive tuberculin test.

Correct Answer: A

Rationale: The correct answer is A because documenting the findings is essential for accurate patient care and communication among healthcare professionals. By documenting the unfamiliar sound heard during auscultation, the nurse ensures that the information is recorded for future reference and potential follow-up assessments or interventions. Waiting 10 minutes (B) may not address the immediate need for documentation. Asking another nurse to double-check (C) may be helpful but does not address the importance of documenting the finding. Asking the patient to take deep breaths (D) is not the appropriate next step when an unfamiliar heart sound is detected; documentation is crucial before further assessment or intervention.

Correct Answer: B

Rationale: The correct answer is B: Providing supplemental oxygen. In COPD, patients often have difficulty breathing due to impaired lung function. Supplemental oxygen helps improve oxygenation and relieves respiratory distress. Prioritizing this intervention is crucial for managing COPD exacerbations and preventing complications. Administering diuretics (A) may be indicated for comorbid conditions like heart failure but is not a priority in managing COPD. Increasing fluid intake (C) may not directly address the patient's respiratory distress. Encouraging bed rest (D) may lead to deconditioning and worsen respiratory function in COPD patients.

Correct Answer: C

Rationale: The correct answer is C: Patient's level of consciousness. Assessing the patient's level of consciousness is crucial in a neurological assessment as it provides immediate information on the overall function of the brain. Changes in consciousness can indicate serious neurological issues such as head injuries or stroke. It is essential to prioritize assessing consciousness first to determine the urgency of the situation. Assessing reflexes (A), cranial nerve function (B), and pupil response (D) are also important in a neurological assessment but come after assessing the patient's level of consciousness, as they provide more specific and detailed information about the neurological status.

Correct Answer: C

Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.