hesi health assessment test bank -Nurselytic

Correct Answer: C

Rationale: The correct answer is C because promoting health in the client is essential in achieving high-level wellness. Nurses play a crucial role in educating, empowering, and supporting clients in making healthy lifestyle choices. By promoting health, nurses help clients prevent illness, maintain optimal well-being, and improve their overall quality of life. Encouraging appointment attendance (choice
A) is important but not solely focused on wellness promotion. Providing information on alternative treatments (choice
B) is valuable but may not directly contribute to high-level wellness. Providing good client care (choice
D) is a fundamental nursing responsibility, but it does not specifically address the promotion of health and wellness.

Correct Answer: D

Rationale: The correct answer is D: Objective. During a physical assessment, the nurse gathers data through observation and measurement, such as vital signs and physical appearance, which are objective and measurable. This type of data is based on facts rather than opinions or interpretations, making it reliable for assessing the client's health status. Patient-centered data (
A) refers to information focused on the client's perspective, subjective data (
B) is based on the client's symptoms or feelings, and unconfirmed data (
C) lacks validation or evidence, making them unreliable for making clinical decisions.

Correct Answer: A

Rationale: The correct answer is A because the purpose of health assessment is not solely to identify the client's major disease process. Health assessment also includes collecting information about the client's health status, clarifying their ability to pay for health care, and evaluating client outcomes. Identifying the disease process is just one component of a comprehensive health assessment. The other choices (B, C,
D) are incorrect because they all represent valid purposes of health assessment. Collecting information about health status helps in understanding the client's overall well-being, clarifying the ability to pay for health care assists in planning appropriate care, and evaluating client outcomes is essential for monitoring progress and adjusting interventions as needed.

Correct Answer: C

Rationale: The correct answer is C: Objective. Objective data in a physical assessment refers to measurable and observable information obtained through physical examination, laboratory tests, and diagnostic procedures. This type of data is crucial as it is based on facts and can be quantified. Subjective data (
A) is based on the patient's feelings and experiences, while patient-centered (
B) refers to care that is tailored to the individual's preferences. Diagnostic (
D) data refers to information obtained through tests to determine a specific condition, which is different from the general data collected during a physical assessment.

Correct Answer: D

Rationale: The correct answer is D - unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it could indicate a serious underlying condition such as endometrial cancer. Hormone replacement therapy can increase the risk of endometrial cancer, so it should not be used in the presence of unexplained vaginal bleeding.

A, B, and C are incorrect:
A: Family history of stroke is not a direct contraindication for hormone replacement therapy. It may influence the decision-making process, but it is not a definitive contraindication.
B: Ovaries removed before age 45 may actually be an indication for hormone replacement therapy to manage symptoms of menopause.
C: Frequent hot flashes and/or night sweats are common symptoms of menopause and are not contraindications for hormone replacement therapy.