A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that it is important to include cultural information in his health assessment to:

Correct Answer: D

Rationale: The correct answer is D: provide culturally sensitive and appropriate care. Including cultural information in the health assessment helps healthcare providers understand the patient's beliefs, practices, and preferences, allowing for tailored care that respects the patient's cultural background. This improves communication, trust, and overall health outcomes. Choice A is incorrect because cultural information does not necessarily identify the cause of an illness. Choice B is incorrect as it overemphasizes diagnosis without considering the patient's cultural context. Choice C is incorrect as it does not directly address the importance of cultural information in healthcare.

Correct Answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. In chronic heart failure, fluid overload can lead to pulmonary congestion, causing shortness of breath. Weight gain is also a key sign of fluid retention. Increased urine output and hypotension (choice B) are more indicative of dehydration. Fatigue and dizziness (choice C) can be nonspecific symptoms and not directly related to fluid overload. Dry mouth and thirst (choice D) are symptoms of dehydration rather than fluid overload in chronic heart failure. Monitoring for shortness of breath and weight gain allows for early detection and intervention in managing fluid overload in patients with chronic heart failure.

Correct Answer: B

Rationale: The correct answer is B because a functional health assessment evaluates various health patterns such as roles, relationships, coping mechanisms, stress tolerance, and lifestyle choices, providing a holistic view of the individual's well-being. Vital signs and circulation (A) are typically included in a physical assessment, not a functional health assessment. Assessing specific organ abnormalities (C) would be part of a focused physical examination or diagnostic testing. Acute symptoms (D) are important to address but do not encompass the comprehensive evaluation of health patterns that a functional health assessment covers.

Correct Answer: D

Rationale: The correct answer is D: Reactions to previous hospitalizations. Before any medical procedure, it is crucial to gather information about the child's previous reactions to hospitalizations to ensure the safety and well-being of the child during the tonsil removal. This information helps healthcare providers anticipate and prevent potential complications based on past experiences. A: The child's birth weight is irrelevant to the tonsil removal procedure and does not impact the current situation. B: The age at which he started to crawl is not relevant to the tonsil removal procedure and does not provide any useful information for the medical staff. C: Whether he has had the measles is not directly related to the tonsil removal procedure and does not influence the immediate care needed for the child.

Correct Answer: A

Rationale: The correct answer is A: Increasing physical activity and managing weight. This is important for stroke prevention as exercise can improve cardiovascular health and help maintain a healthy weight, reducing the risk of another stroke. Increasing sodium intake (B) can actually elevate blood pressure, increasing stroke risk. Avoiding physical activity (C) can lead to a sedentary lifestyle, which is detrimental to stroke prevention. Consuming high-calorie, high-fat foods (D) can contribute to obesity and other risk factors for stroke. Prioritizing physical activity and weight management aligns with evidence-based guidelines for stroke prevention.

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: D

Rationale: The correct answer is D because it provides a thorough list of specific childhood illnesses and confirms the patient's denial of having had them. This approach ensures comprehensive documentation and accuracy. Choice A is vague and lacks specificity, potentially leading to misunderstandings. Choice B focuses on the patient's perception of their health rather than actual illnesses. Choice C mentions the patient's sister and measles, which is irrelevant to the patient's own medical history. Overall, choice D is the most accurate and relevant option for documenting the patient's childhood illnesses.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In ARDS, the primary issue is hypoxemia due to impaired gas exchange in the lungs. Administering oxygen helps to increase the oxygen levels in the blood, improving oxygenation to vital organs. Corticosteroids (B) are not indicated as they have not shown consistent benefit in ARDS treatment. Bronchodilators (C) are not effective as ARDS is not primarily a bronchoconstrictive disorder. Applying an ice pack to the chest (D) is not relevant and will not address the underlying hypoxemia. Administering oxygen is the most effective and essential intervention to correct hypoxemia in ARDS.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client is experiencing respiratory distress, the priority intervention is to open up the airways to improve breathing. Bronchodilators help relax and widen the airways, making it easier for the client to breathe. This intervention addresses the immediate need for improved respiratory function. Administering corticosteroids (choices B and C) may be beneficial in some cases but is not the priority in acute respiratory distress. Monitoring respiratory rate (choice D) is important but does not directly address the underlying issue of airway constriction in respiratory distress.