test bank for health assessment

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. This is the priority action because managing pain is crucial in providing comfort and reducing distress for the client with a severe burn. Pain relief helps in improving the client's overall well-being and promotes better recovery. Administering corticosteroids (Choice B) is not the priority as pain relief takes precedence. Monitoring for infection (Choice C) is important but not the immediate priority. Applying dressings (Choice D) is also important but should come after administering pain relief.

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.

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: Reorient the client. This is the first step because confusion post-operatively could be due to anesthesia, pain medications, or disorientation. Reorienting the client helps bring them back to reality and decrease anxiety. B: Monitoring for signs of infection would be important but not the initial step for confusion. C: Monitoring serum electrolytes is important but not the immediate priority for confusion. D: Applying a cold compress is not relevant for confusion in a post-operative client.

Correct Answer: B

Rationale: The correct answer is B: increased fibrinogen. In DIC, there is consumption of coagulation factors leading to decreased fibrinogen levels. Heparin therapy helps by inhibiting further thrombus formation, allowing the body to replenish fibrinogen levels. Increased fibrinogen indicates a positive response. Incorrect choices: A) increased platelet count is not specific to Heparin therapy in DIC, C) decreased fibrin split products indicate ongoing coagulation, not a positive response, and D) decreased bleeding is a general response and not specific to Heparin therapy in DIC.