during the care of a client with legionnaires disease which finding would require the nurses immediate attention
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Nursing Elites

HESI LPN

Community Health HESI Exam

1. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

Correct answer: D

Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.

2. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

Correct answer: A

Rationale: The correct answer is A. Focusing on the older children's needs during the initial days at home is crucial as it helps them feel secure and valued during the transition. This approach allows the children to adjust to the new family dynamics and feel included in the care of their newborn sister. Choice B is incorrect as it focuses on tasks rather than addressing the children's emotional needs. Choice C is not the initial step and does not involve directly addressing the children's needs. Choice D puts the decision-making burden on the children rather than providing guidance and support.

3. Which of the following statements is correct regarding community health nursing?

Correct answer: A

Rationale: The correct statement is that evaluation of the health status of individuals and families should be done in consultation with them. This approach ensures that the assessment is accurate and takes into account the perspectives and concerns of the individuals and families involved. Choice B is incorrect because determining the needs of the community should involve input from various stakeholders, not solely the PHN. Choice C is incorrect as the provision of PHN care can be influenced by the policies of the agency or organization where the nurse works. Choice D is also incorrect as while the DOH may play a role in setting standards, the professional growth and development of a PHN is typically a personal and professional responsibility.

4. A client with a history of seizures is receiving phenytoin (Dilantin). The nurse should monitor the client for which of the following side effects?

Correct answer: C

Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.

5. The nurse is caring for a 4-year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best response by the nurse should be that

Correct answer: B

Rationale: The correct answer is B. Greenstick fractures are common in children because their bones are softer and more porous than adult bones, leading to incomplete breaks when force is applied. Choice A is incorrect as greenstick fractures are not due to bone flexibility but rather the porous nature of children's bones. Choice C is incorrect as it describes a buckle or torus type break, which is not characteristic of a greenstick fracture. Choice D is incorrect as greenstick fractures do not involve bone fragments remaining attached by a periosteal hinge.

Similar Questions

A client presents at a community-based clinic with complaints of shortness of breath, headache, dizziness, and nausea. During the assessment, the nurse learns that the client is a migrant worker who often uses a gasoline-powered pressure washer to clean equipment and farm buildings. Which type of poisoning is the most likely etiology of this client's symptoms?
A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?
When providing nursing care to a client receiving oxygen therapy via a nasal cannula, which of the following interventions would be appropriate?
A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?
When admitting a client with Parkinson's disease to the home healthcare service, which nursing diagnosis should have priority in planning care?

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