test bank for health assessment

Correct Answer: A

Rationale: The correct answer is A: Open the airway. This is the first intervention because ensuring a clear airway is crucial for adequate oxygenation. If the airway is obstructed, oxygen administered or suctioning performed may not be effective. Checking for breathing should follow airway opening. Administering oxygen can be done once the airway is established. Suctioning is not the priority unless there is evidence of airway obstruction.

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: 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: B

Rationale: Rationale: 1. pH within normal range (7.35-7.45) indicates homeostasis. 2. PO2 (normal 75-100 mmHg) and PCO2 (normal 35-45 mmHg) are slightly deviated but not clinically significant. 3. HCO3 within normal range (22-26 mEq/L) further supports overall balance. Summary: A: Incorrect - HCO3 level is within normal range, ruling out metabolic alkalosis. C: Incorrect - PCO2 is within normal range, ruling out respiratory acidosis. D: Incorrect - PCO2 is slightly low but not significantly, ruling out respiratory alkalosis. Overall, the ABG values indicate the body is in homeostasis.

Correct Answer: D

Rationale: Step-by-step rationale for why answer D is correct: 1. Empathy and respect: By saying "I respect your decision to choose surgery," you acknowledge her autonomy and decision-making. 2. Supportive approach: This response shows understanding and non-judgmental support for her choice. 3. Person-centered care: Recognizing her individual needs and choices is crucial in providing quality healthcare. Summary: A: Irrelevant and insensitive to her medical needs. B: Disregards her current situation and overlooks the complexity of weight loss. C: Implies a one-size-fits-all approach without considering her specific circumstances. D: Demonstrates respect, understanding, and support for her decision-making.