test bank for health assessment

Correct Answer: A

Rationale: The nurse should first administer aspirin to a client with chest pain as it helps prevent blood clot formation during a possible heart attack. Aspirin inhibits platelet aggregation, reducing the risk of further blockage in the coronary arteries. Administering aspirin promptly can improve the client's outcomes. Performing an ECG, monitoring vital signs, or providing a meal plan are important but should come after administering aspirin in the initial management of chest pain to prioritize the client's safety and well-being.

Correct Answer: A

Rationale: The correct action is to administer IV fluids when a client's blood pressure drops significantly. This helps increase blood volume and improve circulation, stabilizing the blood pressure. Administering pain medication (B) does not address the root cause of low blood pressure. Applying a heating pad (C) is not effective in treating low blood pressure. Monitoring the client's respiratory rate (D) is important but not the immediate action needed to address a significant drop in blood pressure.

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: Assess airway. In caring for a client with a traumatic head injury, the first priority is to ensure there is a clear airway to maintain oxygenation and ventilation, which is crucial for brain function. If the airway is compromised, it can lead to hypoxia and further brain damage. Providing pain relief (B) is important but not the immediate priority. Monitoring intracranial pressure (C) is essential but comes after ensuring a patent airway. Maintaining a quiet environment (D) can help reduce stimulation, but it is not as critical as assessing the airway for immediate intervention.

Correct Answer: B

Rationale: The correct answer is B: Increase weight. For a client at risk for nutritional problems, increasing weight is crucial to improve overall health and address potential malnutrition. This goal focuses on restoring and maintaining a healthy weight, which is essential for proper functioning of the body and reducing the risk of various health issues. Promoting healthy nutritional practices (choice A) is important but may not address the immediate need for weight gain. Treating complications of malnutrition (choice C) is reactive rather than proactive. Increasing protein in the diet (choice D) is helpful but not comprehensive enough to address the overall nutritional needs of the client.