health assessment test bank jarvis

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the first priority because it helps prevent further injury to the spinal cord. By immobilizing the spine, the nurse ensures that any movement doesn't worsen the existing injury. Placing the client in a supine position (B) can be done after immobilization. Administering analgesics (C) should not be done before assessing the extent of the injury. Assessing the airway (D) is important but should come after immobilizing the spine to prevent any unnecessary movement.

Correct Answer: A

Rationale: The correct answer is A: Administer antiepileptics. This is the most appropriate intervention for a client with a history of seizures as antiepileptic medications help prevent or reduce the frequency of seizures. Monitoring vital signs (B) is important but does not directly address the underlying issue of seizures. Oxygen therapy (C) may be needed during a seizure but does not prevent future episodes. Monitoring ECG (D) may provide information on cardiac function but is not the primary intervention for seizures. Administering antiepileptics is essential for seizure management.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. This is the best nursing action for a client with a wound infection because antibiotics are necessary to treat the infection at its source, targeting the bacteria causing the infection. Antibiotics help prevent the infection from spreading and promote healing. Explanation of why other choices are incorrect: B: Applying a sterile dressing is important for wound care but does not address the underlying infection. C: Monitoring blood pressure is important for overall patient assessment but does not directly treat the wound infection. D: Placing the client in a sitting position is not relevant to treating a wound infection.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates empathy and addresses the patient's potential emotions directly. By asking if the patient feels nervous or worried about the pregnancy, the nurse acknowledges the observed nonverbal behaviors and opens the door for the patient to express their feelings. This approach shows sensitivity and may help the patient feel understood and supported. Choice A is incorrect because directly asking the patient to explain what they are feeling might come off as intrusive and could make the patient uncomfortable. Choice B is not ideal as remaining silent may lead to missed opportunities for the patient to share their concerns. Choice D, while important, does not address the specific nonverbal cues observed and may not prompt the patient to open up about their emotions.

Correct Answer: B

Rationale: The correct answer is B: Initiate a stroke protocol. This is the most appropriate response because time is critical in treating a stroke. By initiating a stroke protocol, the nurse ensures that the client receives prompt and appropriate care, including timely evaluation, imaging studies, and potential interventions such as administering clot-busting medication. Performing a neurological assessment (A) is important but may delay crucial interventions. Positioning the client on their side (C) is essential for airway protection but should not be the initial priority. Starting a CT scan (D) is important for diagnosis but should not delay the initiation of the stroke protocol, which includes obtaining imaging studies.