jarvis health assessment test bank

Correct Answer: C

Rationale: The correct answer is C: Severity. In the PQRSTU mnemonic, "S" stands for Severity, which refers to the intensity or seriousness of the symptoms experienced by the patient. This is crucial in assessing the impact of the problem on the patient's health and well-being. Incorrect choices: A: Swelling - Swelling is a physical symptom and does not encompass all aspects of the patient's perception. B: Subjectivity - While the patient's subjective experience is important, it does not specifically refer to severity. D: Symptoms - While symptoms are part of the patient's perception, the "S" in PQRSTU specifically focuses on the severity of those symptoms.

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: A

Rationale: The correct answer is A: Administer fluids. In shock, the most crucial intervention is to restore perfusion by increasing circulating volume. Administering fluids helps to improve tissue perfusion and oxygen delivery. This is essential for stabilizing the client's condition. Monitoring cardiac rhythm (B) and blood pressure (C) are important, but addressing the underlying issue of hypovolemia by giving fluids takes precedence. Providing IV antibiotics (D) is not the primary intervention for shock, as the immediate focus should be on restoring blood flow and oxygen delivery.

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.

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.