jarvis health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. When a client presents with symptoms of hypoglycemia, the nurse should prioritize raising the blood sugar levels immediately to prevent further complications. Administering glucose helps to quickly address the low blood sugar levels and alleviate symptoms. Monitoring blood glucose (B) is important but not the first step in an acute situation. Administering insulin (C) would worsen hypoglycemia. Monitoring for arrhythmias (D) is not the primary concern when dealing with hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A - Administer IV fluids. This is the priority intervention for a client with suspected hypovolemia and hypotension as it helps to restore intravascular volume and improve blood pressure. IV fluids will address the underlying cause of hypotension by increasing circulating volume. Monitoring blood pressure (B) is important but administering IV fluids takes precedence. Administering corticosteroids (C) is not indicated for hypovolemia and hypotension. Administering oxygen (D) may be necessary if there is evidence of hypoxia, but addressing fluid volume status is the primary concern in this scenario.

Correct Answer: C

Rationale: The most important goal for a nurse when implementing care for a patient with a chronic illness is to prevent future complications (Choice C). This is because chronic illnesses are long-term conditions that require ongoing management to minimize the risk of complications and improve the patient's quality of life. By preventing future complications, the nurse helps maintain the patient's health and prevents the progression of the disease. Providing emotional support (Choice D) is important but not the most crucial goal in this context. While reducing symptoms (Choice B) is important, preventing future complications takes precedence as it addresses the underlying cause of the illness. Curing the disease (Choice A) may not always be feasible for chronic illnesses, making prevention of complications a more realistic and essential goal.

Correct Answer: A

Rationale: The correct answer is A because as a nurse, it is essential to respect and accommodate the cultural beliefs and preferences of patients. By offering to assist in arranging for the presence of the medicine woman, the nurse shows empathy, cultural competence, and patient-centered care. This approach promotes trust, communication, and collaboration with the patient. Choice B is incorrect as it disregards the patient's request and shows a lack of respect for their beliefs. Choice C is incorrect as it dismisses the significance of the patient's request, which can impact the therapeutic relationship. Choice D is incorrect as it invalidates the patient's beliefs and cultural practices, which can lead to feelings of disrespect and lack of trust.

Correct Answer: A

Rationale: The correct answer is A: Cleanse and dress the wound. This intervention is essential as it helps prevent infection, promotes healing, and maintains a moist wound environment. Cleansing removes debris and bacteria, while dressing protects the wound from external contaminants. Administering antibiotics (choice B) is not the initial intervention for an open wound. Placing a sterile dressing (choice C) is important, but cleansing the wound first is crucial. Ensuring wound care is sterile (choice D) is important, but the primary focus should be on cleansing and dressing the wound.