test bank for health assessment

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for an allergic reaction as it helps to reverse severe symptoms like swelling, difficulty breathing, and low blood pressure. Administering epinephrine promptly can prevent the allergic reaction from escalating into a life-threatening situation. Antihistamines (choice B) may be given after epinephrine for symptom relief but are not as immediate in action. Monitoring vital signs (choice C) is important, but administering epinephrine takes precedence in managing the allergic reaction. Providing a cold compress (choice D) may help with local swelling but does not address the systemic effects of the allergic reaction.

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: D

Rationale: A focused assessment is more in-depth on specific issues, providing detailed information on a particular problem or concern. This allows for targeted interventions and treatment strategies. In contrast, a comprehensive assessment covers the body head to toe and involves all body systems, which may not be necessary when focusing on a specific issue. Occurring only in the clinic is a limitation to choice B, as assessments can be conducted in various settings. Involving all body systems, as stated in choice C, is not the primary focus of a focused assessment.

Correct Answer: C

Rationale: The correct answer is C: Ensure the lens is centered on the cornea. This is important because removing a hard contact lens that is not centered can cause damage to the cornea or surrounding structures. By ensuring the lens is properly positioned on the cornea before attempting removal, the risk of injury is minimized. Explanation of other choices: A: Gently irrigating the eye with solution is not the correct procedure for removing hard contact lenses as it does not address the specific task of lens removal. B: Grasping the lens with a gentle pinching motion can be harmful if the lens is not centered, leading to potential damage to the eye. D: Using sterile gloves before attempting removal is important for hygiene but does not directly affect the safe removal of hard contact lenses from an unresponsive client.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. The nurse's first action in treating hypoglycemia is to increase the client's blood glucose levels to prevent further complications. Administering glucose helps quickly raise blood sugar levels, addressing the immediate issue. Options B, C, and D are incorrect as administering insulin would further decrease blood sugar levels, administering oxygen is not the primary intervention for hypoglycemia, and administering antipyretics is used for reducing fever, not treating hypoglycemia.