health assessment exam 2 test bank

Correct Answer: C

Rationale: The correct answer is C: A patient's perception of his or her health status. In a total health database for a well person, it is important to include the patient's own perception of their health status as it provides valuable insights into their overall well-being and can help detect any potential health issues early on. This information is crucial for preventive care and promoting a patient-centered approach to healthcare. A: Nursing goals for the patient - This information would be relevant for a patient with specific health goals or conditions but not necessarily for a well person. B: Anticipated growth and development patterns - This information is more relevant for pediatric or adolescent populations rather than for a well adult. D: The nurse's perception of disease as related to this patient - The nurse's perception is subjective and not as valuable as the patient's own perception in understanding their health status.

Correct Answer: B

Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination. Incorrect Answers: A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention. C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion. D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.

Correct Answer: B

Rationale: The correct answer is B: Atrial fibrillation. Patients with a history of stroke are at an increased risk of atrial fibrillation, a common cause of ischemic stroke. Monitoring for signs of atrial fibrillation such as irregular heartbeat, palpitations, dizziness, and chest discomfort is crucial for early detection and prevention of recurrent strokes. Pulmonary embolism (A), chronic kidney disease (C), and sepsis (D) are not directly associated with a history of stroke and would not be the primary focus of monitoring in this case.

Correct Answer: A

Rationale: The correct answer is A: Administering diuretics as prescribed. Diuretics help reduce fluid retention in patients with heart failure, relieving symptoms like edema and shortness of breath. Prioritizing diuretics can help manage the patient's fluid balance and improve heart function. Encouraging increased fluid intake (B) is contraindicated as it can worsen fluid overload. Restricting sodium intake (C) is important in heart failure management but not the top priority over administering diuretics. Administering pain medications (D) is not a priority intervention for chronic heart failure management.

Correct Answer: C

Rationale: The correct answer is C because spirituality is a personal and intrinsic search for meaning and purpose in life, which is central to the human experience. This definition aligns with the concept of spirituality as a journey of self-discovery and reflection, independent of organized religion or cultural background. Explanation for why other choices are incorrect: A: Worshiping a higher power within an organization implies a religious practice rather than spirituality, which is more individualistic and introspective. B: Attendance at a specific house of worship is a religious practice, not necessarily reflective of spirituality, which can exist outside formal religious institutions. D: While spirituality can be influenced by cultural background, it is not solely tied to it, as it transcends social, ethnic, and historical boundaries.