health assessment test bank

Correct Answer: A

Rationale: Step-by-step rationale for choosing Albuterol as the correct answer: 1. Albuterol is a rapid-acting bronchodilator that provides immediate relief by relaxing the airway muscles during asthma exacerbation. 2. It is the first-line medication recommended by guidelines for acute asthma attacks due to its quick onset of action. 3. Albuterol helps in opening the airways, improving airflow, and relieving symptoms like shortness of breath and wheezing. 4. Epinephrine is not the first choice for asthma exacerbation as it can have more systemic side effects. 5. Levalbuterol is a similar medication to Albuterol but may not be as widely available or cost-effective. 6. IV corticosteroids are important for long-term control but take longer to show effects, making them less suitable as the initial treatment for acute exacerbation.

Correct Answer: A

Rationale: Step 1: Lisinopril is an ACE inhibitor commonly prescribed post-myocardial infarction to reduce strain on the heart and prevent further damage. Step 2: ACE inhibitors like Lisinopril help lower blood pressure and improve heart function. Step 3: By reducing the workload on the heart, Lisinopril can help prevent complications post-MI. Step 4: Acetaminophen (B) is a pain reliever and does not address the cardiovascular issues post-MI. Step 5: Furosemide (C) and Hydrochlorothiazide (D) are diuretics typically used for managing fluid retention, not the primary focus after an MI. Summary: Lisinopril is the correct choice as it helps improve heart function and prevent complications post-MI, unlike the other options which do not directly address the cardiovascular issues associated with MI.

Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open the airways, relieving wheezing in asthma patients. It is the first-line treatment for acute asthma exacerbations. Antihistamines (B) do not treat asthma symptoms. Monitoring for infection (C) is important but not the immediate action for wheezing. Epinephrine (D) is used for severe allergic reactions, not routine asthma management.

Correct Answer: B

Rationale: Step 1: The nurse should prioritize collecting data based on the client's acuity to address immediate needs and ensure patient safety. Step 2: Acuity determines the urgency and intensity of care required, guiding the assessment focus. Step 3: Time available or client cooperation may influence the depth of assessment but do not dictate the data collected. Step 4: The onset of symptoms is important for history-taking but not the primary factor in determining assessment data.

Correct Answer: D

Rationale: The correct answer is D because it indicates a potential concern about the girl's mental health. This behavior may suggest a difficulty in socializing with peers of her own age, which could be a sign of emotional distress or developmental issues. This is concerning in the context of her parents' bitter divorce. A: Clinging to her mother is a common behavior for a child going through a stressful situation, so it may not necessarily indicate a mental health issue. B: Appearing angry and avoiding eye contact could also be a normal reaction to stress or discomfort. C: Riding a tricycle is a typical activity for a 5-year-old and may not directly relate to mental health concerns.