test bank for health assessment

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. In an acute asthma attack, the priority is to open the airways and improve breathing. Bronchodilators work quickly to relax the muscles around the airways, allowing the client to breathe easier. Corticosteroids are used for long-term control, not immediate relief. Oxygen therapy may be needed if the client's oxygen levels are low. Pain medication is not indicated for an acute asthma attack as the primary issue is airway constriction, not pain. Administering bronchodilators first helps address the immediate breathing difficulty in an asthma attack.

Correct Answer: D

Rationale: In emergency situations, time is crucial. Emergency assessment is the most appropriate as it focuses on quickly identifying and addressing life-threatening issues. It involves a rapid but systematic evaluation of the patient's airway, breathing, circulation, and disability. Head-to-toe assessment (A) and comprehensive assessment (C) are too time-consuming in emergencies, whereas focused assessment (B) may not cover all critical aspects.

Correct Answer: A

Rationale: The correct answer is A because health assessment helps establish a baseline database for comparison in future assessments, allowing for tracking of changes in health status over time. It provides essential information for identifying health issues and developing appropriate interventions. Choice B is incorrect as establishing rapport is a benefit but not the primary purpose. Choice C is incorrect as health assessment is typically conducted by primary healthcare providers, not specialists. Choice D is incorrect as quantifying pain is just one aspect of health assessment, not its primary purpose.

Correct Answer: A

Rationale: The correct answer is A: Assess vital signs. This is the first intervention because it provides immediate information on the client's condition and helps determine the severity of the pain. Monitoring vital signs can reveal signs of shock, dehydration, or other serious complications. Performing a CT scan (B) is not the first priority as it requires time and resources. Monitoring urine output (C) may be important but not as immediate as assessing vital signs. Monitoring for signs of shock (D) can be included in assessing vital signs but is not the primary intervention.

Correct Answer: A

Rationale: The correct answer is A: Administer antiepileptic drugs. This is the most important nursing action for a client with a history of seizures because antiepileptic drugs help prevent or reduce the frequency and severity of seizures. By ensuring the client receives their prescribed medication, the nurse can help manage the condition effectively. Placing the client on their side (B) is important to prevent aspiration if a seizure occurs, but administering antiepileptic drugs is more crucial for long-term management. Checking the airway (C) is important during and after a seizure but does not address the underlying cause. Monitoring for hypoglycemia (D) is important as a potential trigger for seizures, but administering antiepileptic drugs takes precedence in managing the condition.