jarvis health assessment test bank

Correct Answer: B

Rationale: The correct answer is B: Administer thrombolytics. Thrombolytics help dissolve blood clots, which may be causing the stroke. Administering thrombolytics promptly can improve blood flow to the brain, potentially reducing the severity of the stroke and its effects, including difficulty speaking. Calling for help (A) is important, but administering thrombolytics should be a priority. Performing a CT scan (C) may help confirm the type of stroke but may delay immediate treatment. Administering bronchodilators (D) is not indicated for difficulty speaking related to stroke.

Correct Answer: A

Rationale: The correct answer is A: Perform a lumbar puncture. This is the first action because diagnosing meningitis requires cerebrospinal fluid analysis obtained through a lumbar puncture. It helps identify the specific type of meningitis (bacterial, viral, or fungal) and guides appropriate treatment. Administering pain relief (B) or oxygen (C) may be necessary but not the initial priority. Administering antibiotics (D) should be based on the results of the lumbar puncture to ensure targeted therapy.

Correct Answer: C

Rationale: The most important goal for a nurse when implementing care for a patient with a chronic illness is to prevent future complications (Choice C). This is because chronic illnesses are long-term conditions that require ongoing management to minimize the risk of complications and improve the patient's quality of life. By preventing future complications, the nurse helps maintain the patient's health and prevents the progression of the disease. Providing emotional support (Choice D) is important but not the most crucial goal in this context. While reducing symptoms (Choice B) is important, preventing future complications takes precedence as it addresses the underlying cause of the illness. Curing the disease (Choice A) may not always be feasible for chronic illnesses, making prevention of complications a more realistic and essential goal.

Correct Answer: B

Rationale: The correct answer is B: Place in a safe environment. This is the priority action because it ensures the client's safety by preventing injury during the seizure. Placing the client in a safe environment involves removing any objects that could harm them, such as sharp objects or furniture. Positioning on their side (choice A) is important after the seizure to prevent aspiration. Applying warm compresses (choice C) is not indicated during a seizure. Inserting an oral airway (choice D) is not recommended as it can be dangerous during a seizure and should only be done if the client is not breathing after the seizure.

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. At 11-12 months, a child should be able to pull themselves to a standing position. Inability to do so suggests possible hip joint instability, a key risk factor for developmental dysplasia of the hip. Refusal to walk (A) is not specific to hip dysplasia. Negative Trendelenburg sign (C) indicates good hip abductor strength, which is not a risk factor. Negative Ortolani sign (D) is a maneuver used for hip joint assessment in infants and is not indicative of hip dysplasia risk at this age.