ATI RN
jarvis physical examination and health assessment 9th edition test bank Questions
Question 1 of 9
A nurse is teaching a patient with diabetes about self-management. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: The correct answer is A because monitoring blood glucose levels regularly is essential for managing diabetes effectively. By monitoring blood glucose levels, the patient can make informed decisions about medication, diet, and exercise. This helps in preventing complications and maintaining blood sugar levels within the target range. Choice B is incorrect because stopping insulin when blood sugar is within the normal range can lead to fluctuations and potential hyperglycemia. Choice C is a good practice but does not specifically address blood sugar management. Choice D is also important but does not encompass all aspects of diabetes management.
Question 2 of 9
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following to prevent complications?
Correct Answer: A
Rationale: Correct Answer: A - Encouraging early ambulation Rationale: 1. Early ambulation helps prevent post-operative complications like blood clots and pneumonia. 2. Movement promotes circulation, aids in lung expansion, and prevents muscle atrophy. 3. It also supports bowel function and helps prevent constipation, a common post-operative issue. 4. Ambulation aids in overall recovery and reduces the risk of complications associated with prolonged immobility. Other Choices: B: Administering pain medication - Important for comfort but not the top priority for preventing complications. C: Providing wound care and dressing changes - Necessary for wound healing but not the immediate priority to prevent complications. D: Monitoring for signs of infection - Critical but not the primary intervention to prevent complications immediately post-op.
Question 3 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 4 of 9
A nurse is caring for a patient with a history of asthma. The nurse should monitor for which of the following signs of an asthma exacerbation?
Correct Answer: B
Rationale: The correct answer is B: Increased wheezing and shortness of breath. During an asthma exacerbation, bronchial airways become inflamed and narrowed, leading to increased wheezing and shortness of breath. This is a classic sign of worsening asthma. Other choices are incorrect because: A) Decreased work of breathing is not expected in an asthma exacerbation as the patient usually struggles to breathe. C) Improved oxygen saturation is unlikely as airway obstruction can lead to decreased oxygen levels. D) Decreased sputum production is not a typical sign of asthma exacerbation; in fact, increased sputum production may occur due to airway inflammation.
Question 5 of 9
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD have impaired lung function, making them at risk for respiratory failure due to inadequate oxygenation. This can occur due to exacerbation of COPD, infections, or other factors. Monitoring for signs of respiratory distress is crucial. A: Pneumonia - While patients with COPD are at higher risk for pneumonia due to impaired lung function, respiratory failure is a more immediate and critical complication to monitor for in this scenario. C: Hypoglycemia - COPD does not directly increase the risk of hypoglycemia, so monitoring for this complication is not a priority in this case. D: Hypertension - Although some patients with COPD may have hypertension, it is not a common complication directly related to COPD. Monitoring for respiratory failure is more essential in this situation.
Question 6 of 9
A pregnant woman states, "I just know labour will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labour." The nurse responds by stating, "Oh, don't worry about labour so much. I have been through it myself, and yes, it is painful, but there are many good medications to decrease the pain." Which of the following statements about this response is true?
Correct Answer: B
Rationale: The correct answer is B because the nurse's response was therapeutic by sharing her own experience to empathize with the patient. This helps establish a connection and validate the patient's feelings. It shows understanding without dismissing the patient's concerns. A is incorrect because the nurse did not provide false reassurance but offered a comforting perspective. C is incorrect as the nurse did not imply that medication was necessary but rather highlighted its availability as an option. D is incorrect since the response did not provide false assurance but rather shared personal experience to offer support.
Question 7 of 9
The review of systems provides the nurse with:
Correct Answer: B
Rationale: Step 1: The review of systems is a systematic approach to assessing the patient's overall health. Step 2: It gathers information about symptoms across different body systems. Step 3: This information helps identify potential health risks and guide health promotion practices. Step 4: Choice B is correct as it aligns with the purpose of the review of systems. Summary: - Choice A is incorrect because it focuses on physical findings only, not the comprehensive assessment. - Choice C is incorrect as the review of systems is not primarily for teaching medical terms. - Choice D is incorrect as it does not provide enough information for diagnosing specific medical problems.
Question 8 of 9
The nurse is interviewing a recent immigrant from Mexico. During the course of the interview, the man leans forward and then finally moves his chair close enough that his knees are nearly touching the nurse's. The nurse begins to feel uncomfortable with his proximity. Which of the following statements describes the most appropriate response by the nurse?
Correct Answer: A
Rationale: The correct answer is A: "Try to relax; this behavior is culturally appropriate for this person." In Mexican culture, close proximity during conversations is common and signifies engagement and trust. By understanding cultural differences, the nurse can avoid misinterpreting the behavior. Moving the chair back (choice B) may be seen as rude. Assuming sexual aggression (choice C) without evidence is inappropriate. Laughing and asking to move away (choice D) may embarrass the individual. Understanding and respecting cultural norms is crucial in providing effective care.
Question 9 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.