jarvis health assessment test bank -Nurselytic

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. At 11-12 months, a child should be able to pull themselves to a standing position. Inability to do so suggests possible hip joint instability, a key risk factor for developmental dysplasia of the hip. Refusal to walk (
A) is not specific to hip dysplasia. Negative Trendelenburg sign (
C) indicates good hip abductor strength, which is not a risk factor. Negative Ortolani sign (
D) is a maneuver used for hip joint assessment in infants and is not indicative of hip dysplasia risk at this age.

Correct Answer: C

Rationale: The most important goal for a nurse when implementing care for a patient with a chronic illness is to prevent future complications (
Choice
C). This is because chronic illnesses are long-term conditions that require ongoing management to minimize the risk of complications and improve the patient's quality of life. By preventing future complications, the nurse helps maintain the patient's health and prevents the progression of the disease. Providing emotional support (
Choice
D) is important but not the most crucial goal in this context. While reducing symptoms (
Choice
B) is important, preventing future complications takes precedence as it addresses the underlying cause of the illness. Curing the disease (
Choice
A) may not always be feasible for chronic illnesses, making prevention of complications a more realistic and essential goal.

Correct Answer: C

Rationale: The primary purpose of an abdominal binder after surgery is to increase circulation. An abdominal binder helps improve blood flow to the surgical site, which can aid in reducing swelling, promoting healing, and preventing complications such as blood clots. It provides gentle compression to support the abdominal muscles and tissues without restricting circulation.


Choice A (Promote comfort) is incorrect because while an abdominal binder may provide some comfort by supporting the abdomen, its primary purpose is not solely for comfort.


Choice B (Prevent infection) is incorrect because an abdominal binder does not directly prevent infection. Infection prevention is primarily achieved through proper wound care and infection control practices.


Choice D (Provide wound care) is incorrect because an abdominal binder does not provide wound care. Wound care involves cleaning, dressing changes, and monitoring for signs of infection, which are separate from the purpose of an abdominal binder.

Correct Answer: B

Rationale: The correct answer is B: secondary prevention. Teaching a client with gonorrhea about reinfection prevention falls under secondary prevention, which aims to detect and treat a disease early to prevent complications and further transmission. This intervention occurs after the client has already been diagnosed with gonorrhea, focusing on preventing reinfection and spreading the infection to others.

A: Primary prevention focuses on preventing the disease from occurring in the first place, such as promoting safe sex practices to prevent gonorrhea infection.
C: Tertiary prevention involves managing and preventing complications of a disease that has already occurred, which is not the case with teaching about reinfection prevention.
D: Primary health care prevention is a broad term that encompasses various aspects of healthcare delivery, but it does not specifically address the prevention of reinfection in a client with gonorrhea.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and vascular damage. Monitoring for DVT is crucial to prevent life-threatening complications like pulmonary embolism. Acute renal failure (
A) is not directly related to stroke and is not a common complication. Pneumonia (
C) may occur but is not the highest priority compared to DVT. Hypertension (
D) is important to monitor but is not the priority in this case as DVT poses a more immediate risk to the patient's health.