health assessment in nursing test bank

Correct Answer: A

Rationale: The correct answer is A: Document the findings on the patient's record. This is the appropriate action because documenting the unfamiliar sound ensures that the information is accurately recorded for future reference. Waiting 10 minutes (B) may not address the issue, as the sound could still be present. Asking another nurse to double-check (C) may lead to subjective interpretations. Asking the patient to take deep breaths (D) may not be relevant to identifying the unfamiliar sound. Recording the finding is crucial for tracking changes in the patient's condition and communicating with other healthcare professionals.

Correct Answer: B

Rationale: The correct answer is B: Respiratory failure. Asthma is a chronic respiratory condition that can lead to respiratory failure if not managed properly. The nurse should monitor for signs of worsening asthma symptoms such as increased respiratory rate, accessory muscle use, and decreased oxygen saturation. Pneumonia (A) is a possible complication but is not directly related to asthma. Anemia (C) and Hyperglycemia (D) are not typically associated with asthma and would not be the primary complications to monitor for in this case.

Correct Answer: C

Rationale: The correct answer is C: Jaundice. Patients with chronic liver disease are at risk for developing jaundice due to impaired liver function leading to the accumulation of bilirubin. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates worsening liver function. Incorrect choices: A: Hypoglycemia - Not directly related to chronic liver disease, more commonly seen in diabetes. B: Hyperglycemia - Not typically associated with chronic liver disease unless the patient has underlying diabetes. D: Anemia - Can be a complication of chronic liver disease, but monitoring for jaundice takes priority due to its direct association with liver dysfunction.

Correct Answer: D

Rationale: The correct answer is D: Open-ended question. This verbal skill allows the patient to provide detailed information and express their feelings freely. By asking the patient to talk more about their shortness of breath, the nurse encourages a comprehensive response. Reflection (A) involves paraphrasing the patient's words, not eliciting more information. Facilitation (B) involves encouraging the patient to continue but does not necessarily prompt open-ended responses. Direct question (C) typically elicits a specific answer and limits the patient's response.

Correct Answer: A

Rationale: The correct answer is A: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels. Monitoring for hyperglycemia is crucial to prevent complications like diabetic ketoacidosis. Hypoglycemia (B) is low blood sugar, dehydration (C) is not directly related to diabetes unless it causes hyperosmolar hyperglycemic state, and hypotension (D) is low blood pressure, which is not a common complication of diabetes. Regular monitoring for hyperglycemia helps in preventing diabetic complications.