What is the primary intervention for a client with an acute myocardial infarction?

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jarvis health assessment test bank Questions

Question 1 of 9

What is the primary intervention for a client with an acute myocardial infarction?

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin helps prevent further clot formation by inhibiting platelet aggregation, reducing the risk of additional heart damage. It is a standard treatment in acute myocardial infarction. Administering morphine (B) may be considered for pain relief but is not the primary intervention. Monitoring vital signs (C) is important, but not the primary intervention. Administering fibrinolytics (D) is indicated in certain cases but is not the primary intervention and requires specific criteria and caution.

Question 2 of 9

What should the nurse prioritize for a client with suspected sepsis?

Correct Answer: B

Rationale: The correct answer is B: Administer antibiotics. In sepsis, timely administration of antibiotics is crucial to combat the underlying infection. Antibiotics target the bacteria causing the sepsis, helping to prevent further spread and worsening of the condition. Administering IV fluids (choice A) is important to maintain blood pressure, but antibiotics take precedence in treating the infection. Providing fluids (choice C) is also important but not the priority over antibiotics. Administering oxygen (choice D) may be necessary for respiratory support in severe cases of sepsis, but it does not address the root cause of the condition like antibiotics do.

Question 3 of 9

What is the step of the nursing process that includes data collection through health history taking, physical examination, and interview?

Correct Answer: D

Rationale: The correct answer is D: Assessment. Assessment is the first step in the nursing process where data is collected through health history, physical examination, and interview. This step helps in identifying the patient's needs and health problems. Planning (A) comes after assessment and involves setting goals and creating a care plan. Diagnosis (B) is the step where nursing diagnoses are formulated based on the assessment data. Evaluation (C) is the final step where the effectiveness of the care plan is assessed. In summary, Assessment is the initial step focused on data collection, making it the correct choice.

Question 4 of 9

A patient is admitted after an automobile accident. The nurse begins the mental health examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse's best approach in this situation is to:

Correct Answer: A

Rationale: The correct approach is to defer the rest of the mental health examination. This is because the patient's symptoms of dysarthria and lethargy indicate a potential medical emergency or brain injury, which should take precedence over the mental health assessment. It is important to first ensure the patient's physical well-being before proceeding with the mental health evaluation. Choice B is incorrect as skipping the language portion of the examination may overlook crucial information related to the patient's condition. Choice C is also incorrect as an in-depth speech evaluation may delay necessary medical interventions. Choice D is incorrect as assuming dysarthria is always linked to severe depression can lead to overlooking urgent medical needs.

Question 5 of 9

Novice nurses, without a background of skills and experience to draw from, are more likely to make their decisions using:

Correct Answer: B

Rationale: The correct answer is B: a set of rules. Novice nurses rely on established guidelines and protocols to make decisions as they lack the experience to rely solely on intuition or journal articles. Rules provide structure and consistency in decision-making, reducing the margin of error. Intuition (choice A) may not be reliable without prior experience. Journal articles (choice C) can be overwhelming and may not directly apply to the specific situation. Advice from supervisors (choice D) can be helpful but may not always be readily available, and it's important for novice nurses to develop their own decision-making skills.

Question 6 of 9

Which of the following should be the nurse's priority when caring for a client who is receiving a blood transfusion?

Correct Answer: B

Rationale: The correct answer is B: Administer fluids. Administering fluids is the priority when caring for a client receiving a blood transfusion to prevent circulatory overload. Vital signs (A) should be monitored before and after the transfusion but are not the priority. Monitoring for transfusion reactions (C) is important but comes after administering fluids. Obtaining a blood sample (D) is not a priority during a blood transfusion. Administering fluids ensures adequate hydration and prevents complications during the transfusion process.

Question 7 of 9

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.

Question 8 of 9

What is the most important nursing intervention for a client with an open fracture?

Correct Answer: A

Rationale: The correct answer is A: Apply a sterile dressing. This is the most important intervention to prevent infection and protect the wound. Applying a sterile dressing helps maintain a clean environment, reduces the risk of contamination, and promotes wound healing. Administering fluids (B) may be necessary but is not the top priority. Administering IV antibiotics (C) may be required but is secondary to wound care. Monitoring for bleeding (D) is important but addressing the wound with a sterile dressing takes precedence to prevent infection.

Question 9 of 9

What is an appropriate response by the nurse to a Native-American woman requesting a medicine woman's presence during fetal heart monitoring?

Correct Answer: A

Rationale: The correct answer is A because it demonstrates cultural competence and respect for the patient's beliefs. It shows willingness to accommodate the patient's request, promoting trust and effective communication. Choice B is incorrect as it dismisses the patient's request and may lead to distrust. Choice C is incorrect as it disregards the patient's cultural beliefs and can be perceived as insensitive. Choice D is incorrect as it invalidates the patient's beliefs and can hinder the therapeutic relationship. Ultimately, choice A is the most appropriate response to promote patient-centered care and build a trusting relationship with the patient.

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