ATI RN
jarvis physical examination and health assessment 9th edition test bank Questions
Question 1 of 5
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 2 of 5
A patient is experiencing dizziness, blurred vision, and nausea. The nurse should first assess the patient's:
Correct Answer: B
Rationale: The correct answer is B, Blood pressure. Dizziness, blurred vision, and nausea can be symptoms of hypotension or hypertension. Assessing the patient's blood pressure first is crucial to determine if the symptoms are related to blood pressure fluctuations. Electrolyte levels (A) and blood glucose levels (C) may be assessed later but do not address the immediate concern. Temperature and respiratory rate (D) are important assessments but are not the priority in this scenario where cardiovascular status needs to be evaluated first.
Question 3 of 5
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.
Question 4 of 5
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 5
The nurse is assessing a new patient who has recently immigrated to CanadWhich of the following questions is appropriate to add to the health history questionnaire?
Correct Answer: B
Rationale: The correct answer is B. It is important to know when the patient immigrated and from which country for understanding potential health risks, cultural factors, and access to healthcare. Choice A is too broad and may not yield relevant health information. Choice C focuses on personal reasons for leaving the home country, which may not be medically relevant. Choice D is forward-looking and may not be necessary for the initial assessment.