ATI RN
jarvis physical examination and health assessment 9th edition test bank Questions
Question 1 of 9
A nurse is caring for a patient with chronic kidney disease. The nurse should monitor for which of the following signs of fluid overload?
Correct Answer: A
Rationale: The correct answer is A, shortness of breath and weight gain, because fluid overload in patients with chronic kidney disease can lead to pulmonary edema and weight gain due to retained fluid. Shortness of breath occurs as the excess fluid accumulates in the lungs. Increased urine output and fatigue (B) are more indicative of dehydration. Dizziness and hypotension (C) are symptoms of hypovolemia, not fluid overload. Nausea and vomiting (D) are nonspecific symptoms and not typically associated with fluid overload.
Question 2 of 9
A 40-year-old woman presents to the clinic with complaints of fatigue and weight gain. On assessment, the nurse finds that the patient has cold intolerance, dry skin, and a slow heart rate. The nurse suspects:
Correct Answer: B
Rationale: The correct answer is B: Hypothyroidism. In this case, the patient's symptoms of fatigue, weight gain, cold intolerance, dry skin, and slow heart rate are indicative of hypothyroidism. The thyroid gland is underactive, leading to decreased production of thyroid hormones, which regulate metabolism. These symptoms align with the typical clinical presentation of hypothyroidism. Other choices are incorrect because hyperthyroidism (choice A) would present with symptoms like weight loss, heat intolerance, and a fast heart rate. Cushing's syndrome (choice C) and Addison's disease (choice D) are both conditions related to the adrenal glands and would have different symptom presentations compared to what is described in the case scenario.
Question 3 of 9
When nursing diagnoses are being classified, which of the following would be considered a risk diagnosis?
Correct Answer: C
Rationale: The correct answer is C because a risk diagnosis involves identifying potential problems that an individual may develop in the future. This type of diagnosis focuses on preemptive measures to prevent or minimize the risk of these potential issues occurring. This is different from options A, B, and D, which do not pertain to future potential problems but rather current levels of wellness, past problems and goals, and strengths respectively. Therefore, option C best aligns with the concept of risk diagnosis in nursing classification.
Question 4 of 9
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B because encouraging deep breathing and coughing exercises helps to improve lung function and prevent complications in pneumonia. This intervention can help clear secretions, improve oxygenation, and prevent respiratory distress. Administering antibiotics (choice A) is important but not the priority for immediate patient care. Providing pain relief (choice C) is essential but addressing respiratory function is more critical. Monitoring oxygen saturation levels (choice D) is necessary, but promoting lung function through exercises takes precedence.
Question 5 of 9
When performing a physical assessment, the first technique the nurse will use is:
Correct Answer: B
Rationale: The correct answer is B: Inspection. This is because visual observation is typically the initial step in a physical assessment to gather information about the patient's overall appearance, skin color, posture, and any obvious abnormalities. Palpation (A) involves touching and feeling for abnormalities, which usually follows inspection. Percussion (C) is the technique of tapping on the body to assess underlying structures, and auscultation (D) is listening to sounds produced by the body, both of which typically come after inspection and palpation. Inspecting the patient first allows the nurse to establish a baseline before moving on to more detailed assessment techniques.
Question 6 of 9
Why is the concept of prevention essential in describing health?
Correct Answer: C
Rationale: The correct answer is C because prevention emphasizes the importance of personal behavior in maintaining health. It highlights the role of individual choices in preventing diseases and promoting well-being. A is incorrect because prevention focuses on proactive measures rather than treating external factors. B is incorrect as it contradicts the importance of prevention in reducing preventable deaths. D is incorrect because prevention is about avoiding health issues before they occur, not treating them after they have developed.
Question 7 of 9
A nurse is teaching a patient about managing hypertension. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C. This statement indicates the need for further education because it suggests the patient plans to stop taking medication once blood pressure is normal, which can lead to hypertension returning. Monitoring blood pressure, taking medication as prescribed, and decreasing sodium intake are all appropriate actions for managing hypertension. Stopping medication abruptly can be dangerous and should only be done under a healthcare provider's guidance.
Question 8 of 9
A patient often seems to have difficulty coming up with the right words. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up was so full that I decided to take the stairs.' The nurse will note on his chart that he is using or experiencing:
Correct Answer: C
Rationale: The correct answer is C: Circumlocution. This patient is using circumlocution, which is a communication strategy where a person describes something in a roundabout way instead of using the specific word. In this case, the patient is describing an elevator as "the thing that you step into that goes up." This is a common feature of language difficulties seen in conditions like aphasia. A: Blocking is when a person suddenly stops speaking in the middle of a sentence due to an inability to recall a word, which is not happening in this scenario. B: Neologism is the creation of new words or phrases, which is not evident here. D: Circumstantiality is a speech pattern where the person includes unnecessary details and goes off on tangents, which is not demonstrated in the patient's response.
Question 9 of 9
The nurse is planning health education for a 65-year-old woman who has had a cerebrovascular accident (stroke) and is aphasic. Which of the following is most important to use when assessing mental health in this situation?
Correct Answer: C
Rationale: The correct answer is C: Please point to articles in the room and parts of the body as I name them. This is the most important assessment for mental health in an aphasic patient post-stroke because it evaluates their comprehension, communication abilities, and cognitive function. Pointing to articles and body parts demonstrates understanding and ability to follow instructions, which are crucial aspects of mental health assessment in this context. A: Please count back from 100 by sevens - This choice involves memory and mathematical abilities, which may not accurately assess mental health in an aphasic patient. B: I will name three items and ask you to repeat them in a few minutes - This choice tests memory recall, which is not as relevant for assessing mental health in an aphasic patient post-stroke. D: What would you do if you found a stamped, addressed envelope on the sidewalk? - This choice assesses problem-solving skills, which may not be the most appropriate indicator of mental health in an aphasic patient.