health assessment test bank

Correct Answer: D

Rationale: The correct answer is D, administering antiepileptic medications. This is because during an active seizure, the priority is to stop the seizure activity. Antiepileptic medications are specifically designed to prevent or reduce the frequency and intensity of seizures. Placing the client on their side and protecting their head (choice A) is important for safety but does not address stopping the seizure. Loosening clothing and ensuring safety (choice B) is also important but does not directly address the seizure itself. Monitoring airway and giving oxygen (choice C) is crucial but does not actively stop the seizure. Therefore, administering antiepileptic medications is the most appropriate intervention to address the root cause of the seizure.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for a patient with diabetes and peripheral neuropathy to prevent complications like diabetic foot ulcers. Daily foot inspections can help detect any injuries or changes early to prevent infection or further damage. It is important to prioritize this over other choices because early intervention can prevent serious consequences. Engaging in weight-bearing exercise (choice B) can be beneficial but may not be the priority in this case. Increasing protein intake (choice C) is not directly related to foot care. Using tight-fitting shoes (choice D) can lead to pressure ulcers and should be avoided.

Correct Answer: A

Rationale: The correct answer is A because tolerance is a physiological phenomenon where the body adapts to a drug, requiring higher doses for the same effect. This is a common occurrence with opioids in chronic pain management. Choice B is incorrect as it refers to drug-seeking behavior, not tolerance. Choice C is incorrect because addiction and physical dependence are different concepts. Choice D is incorrect as it relates to a specific scenario of substance abuse alongside chronic pain, not the mechanism behind the need for increased opioid doses in chronic pain management.

Correct Answer: B

Rationale: The correct first intervention for a client suspected of having a stroke is to perform a CT scan (Choice B). This is because a CT scan can quickly identify the type of stroke (ischemic or hemorrhagic) and guide treatment decisions. Monitoring neurological status (Choice A) can be important but does not provide a definitive diagnosis. Administering fibrinolytics (Choice C) should only be done after confirming the type of stroke to avoid complications. Performing an MRI (Choice D) is more time-consuming and may not be feasible in the acute setting where quick intervention is crucial. Therefore, a CT scan is the most appropriate initial intervention for a suspected stroke.

Correct Answer: C

Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice B) and introspective (choice D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.