test bank for health assessment

Correct Answer: A

Rationale: The correct answer is A: coma. High ammonia levels can lead to hepatic encephalopathy, causing impaired brain function and potentially leading to coma. Edema (B) is typically associated with fluid retention, not high ammonia levels. Hypoxia (C) is a condition of low oxygen levels, not directly related to high ammonia levels. Polyuria (D) is excessive urination, which is not a common sign of high ammonia levels.

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: Administer bronchodilators. In an acute asthma attack, the priority is to open the airways and improve breathing. Bronchodilators work quickly to relax the muscles around the airways, allowing the client to breathe easier. Corticosteroids are used for long-term control, not immediate relief. Oxygen therapy may be needed if the client's oxygen levels are low. Pain medication is not indicated for an acute asthma attack as the primary issue is airway constriction, not pain. Administering bronchodilators first helps address the immediate breathing difficulty in an asthma attack.

Correct Answer: D

Rationale: The correct answer is D: Administer morphine. Administering morphine is the first intervention for a client experiencing a myocardial infarction (MI) to help relieve pain and reduce anxiety. Oxygen may not be necessary if the client is not hypoxic. Administering aspirin is important but usually follows morphine. Monitoring ECG is crucial, but not the first intervention to address the immediate symptoms of MI.

Correct Answer: B

Rationale: The correct answer is B: increased fibrinogen. In DIC, there is consumption of coagulation factors leading to decreased fibrinogen levels. Heparin therapy helps by inhibiting further thrombus formation, allowing the body to replenish fibrinogen levels. Increased fibrinogen indicates a positive response. Incorrect choices: A) increased platelet count is not specific to Heparin therapy in DIC, C) decreased fibrin split products indicate ongoing coagulation, not a positive response, and D) decreased bleeding is a general response and not specific to Heparin therapy in DIC.