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: C

Rationale: The correct answer is C: Decreasing intake of trans fats. Trans fats are known to increase LDL cholesterol levels, which are considered "bad" cholesterol. By reducing trans fats in the diet, the patient can lower their cholesterol levels. Saturated fats (choice A) can also increase LDL cholesterol, so increasing intake is not beneficial. Dietary fiber (choice B) helps lower cholesterol by binding to cholesterol in the digestive system, so decreasing intake would not be beneficial. Processed sugars (choice D) do not directly impact cholesterol levels, so increasing intake would not help lower cholesterol. Overall, choosing option C is the most effective dietary change for managing high cholesterol.

Correct Answer: A

Rationale: The correct answer is A because as people age, they accumulate more life experiences, medical history, and details to share. This can lead to longer conversations during interviews. Choice B is incorrect as not all older adults are lonely and seek conversation. Choice C is incorrect because aging does not necessarily equate to a loss of mental abilities. Choice D is incorrect as hearing loss is not a universal issue among older adults and does not significantly impact the length of interviews.

Correct Answer: A

Rationale: The correct answer is A: "Does Salil take medicine?" This is the best question because it is simple, direct, and focuses on gathering important medical information. It is clear and easy to understand even with a language barrier. Choice B is irrelevant and not related to the patient's health status. Choice C assumes symptoms without context. Choice D is inappropriate as it refers to the patient in the third person and includes a leading statement. Asking about medication directly is the most appropriate approach in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Preventing deep vein thrombosis (DVT). It is the most important nursing priority after hip replacement surgery because patients are at high risk for DVT due to immobility and altered blood flow. DVT can lead to serious complications like pulmonary embolism. Monitoring for infection (B) is important but preventing DVT takes precedence. Managing pain (A) is essential but not the top priority. Ensuring proper positioning (D) is important for preventing complications, but DVT prevention is more critical post-hip replacement surgery.