health assessment test bank jarvis

Correct Answer: C

Rationale: The correct answer is C: pernicious anemia. Pernicious anemia is caused by vitamin B12 deficiency, leading to impaired red blood cell production but does not directly affect clotting factors. Metastatic liver cancer (A) can cause liver dysfunction and decreased production of clotting factors, increasing bleeding risk. Gram-negative septicemia (B) can lead to disseminated intravascular coagulation and excessive bleeding. Iron-deficiency anemia (D) can result in microcytic red blood cells and decreased oxygen delivery but does not directly increase bleeding potential.

Correct Answer: D

Rationale: The correct answer is D because completing the grieving process before birth is not appropriate when planning care for a client undergoing genetic counseling. This is because genetic counseling aims to provide information and support to help clients make informed decisions about their pregnancy or future child's health. Grieving before birth implies assuming a negative outcome before all information is gathered, which can be premature and may not align with the purpose of genetic counseling. Choices A, B, and C are allowed as they involve valid actions such as decision-making, preparation, and accessing support services, all of which are important aspects of genetic counseling.

Correct Answer: A

Rationale: The correct answer is A: Secure the airway. This is the highest priority for a nurse treating a client with a stab wound to the chest because airway management is crucial for ensuring the client can breathe effectively. If the airway is compromised, the client may not be able to oxygenate properly, leading to serious complications or even death. Administering oxygen (choice B) can help with oxygenation but is not as critical as ensuring the airway is clear. Turning the client (choice C) or applying an abdominal binder (choice D) are not appropriate actions for a stab wound to the chest and would not address the immediate life-threatening issue of airway compromise.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the first priority because it helps prevent further injury to the spinal cord. By immobilizing the spine, the nurse ensures that any movement doesn't worsen the existing injury. Placing the client in a supine position (B) can be done after immobilization. Administering analgesics (C) should not be done before assessing the extent of the injury. Assessing the airway (D) is important but should come after immobilizing the spine to prevent any unnecessary movement.

Correct Answer: D

Rationale: The correct answer is D: Head to toe. The head-to-toe assessment is efficient because it follows a systematic approach starting from the head and progressing downward, ensuring that all body parts are assessed while maintaining the patient's modesty. This approach allows the nurse to gather comprehensive data without compromising the patient's privacy. A: Body systems - While assessing by body systems is important, it may not provide the same level of modesty as the head-to-toe approach. B: Functional - Assessing by function focuses on specific body functions rather than a comprehensive assessment of all body systems. It may not address all aspects of the patient's health. C: Focused - A focused assessment targets specific health issues and may not cover all body systems comprehensively, potentially missing important findings.