health assessment exam 1 test bank

Correct Answer: B

Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location. A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs. C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs. D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.

Correct Answer: C

Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.

Correct Answer: C

Rationale: The correct answer is C: Monitoring for signs of hemorrhage. This is the priority intervention because post-cesarean section hemorrhage is a life-threatening complication that requires immediate attention. The nurse should monitor the patient's vital signs, uterine firmness, and amount of vaginal bleeding to detect any signs of hemorrhage and take prompt action if necessary. Option A is incorrect because pain management is important but not the priority in this situation. Option B is also incorrect as breastfeeding can be encouraged after the patient's condition is stable. Option D is not the priority as preventing deep vein thrombosis is important but not as urgent as monitoring for hemorrhage.

Correct Answer: C

Rationale: The correct answer is C: Senile angiomas. Senile angiomas are common benign growths of small blood vessels that appear as bright-red dots on the skin, commonly seen in older individuals. In this case, the patient is 32 years old, which is relatively young for an appearance of senile angiomas, but still within the possible age range. Anasarca (A) is generalized edema, not related to the described skin condition. Scleroderma (B) is a connective tissue disorder characterized by skin thickening and not associated with bright-red dots. Latent myeloma (D) is a type of bone marrow cancer and not related to the skin findings described.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Post-operative hip replacement patients are at high risk for DVT due to immobility and surgical trauma. The nurse should monitor for signs such as swelling, redness, and pain in the affected leg. DVT can lead to serious complications like pulmonary embolism if not detected early. Choices A, C, and D are incorrect because while pneumonia, wound infection, and hypoglycemia are also potential post-operative complications, they are not as directly associated with hip replacement surgery as DVT.