while caring for a child with reyes syndrome the nurse should give which action the highest priority
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Nursing Elites

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Community Health HESI Test Bank

1. When caring for a child with Reye's Syndrome, which action should the nurse give the highest priority?

Correct answer: C

Rationale: Assessing the level of consciousness is crucial when caring for a child with Reye's Syndrome. Changes in neurological status can indicate deterioration of the condition, necessitating immediate medical attention. Monitoring intake and output is important but not the highest priority compared to assessing the child's level of consciousness. Providing good skin care and assisting with range of motion are also important aspects of care but take a lower priority than assessing the child's neurological status in this critical condition.

2. In this municipality, what should the nursing health care plan focus on?

Correct answer: C

Rationale: In this municipality, the nursing health care plan should primarily focus on health promotion and disease prevention. This approach addresses the underlying causes of health problems, promotes overall well-being, and helps prevent illnesses before they occur. While rehabilitative and curative services are important, health promotion and disease prevention are crucial for fostering a healthier community in the long term. Therefore, choices A, B, and D are not the best options as they do not prioritize preventing health issues at the root cause.

3. What does the nurse perform to determine the family nursing problems/needs?

Correct answer: C

Rationale: The correct answer is C: assessment. Assessment is the initial step in identifying family nursing problems/needs. During assessment, the nurse collects data to understand the family's health status, strengths, weaknesses, and potential areas for intervention. This process helps in developing an accurate picture of the family's situation. Choices A, B, and D are incorrect because goal setting, family health care plan formulation, and evaluation come after the assessment phase. Goal setting occurs once the issues are identified, the family health care plan is developed based on assessment findings, and evaluation is the final step to assess the effectiveness of the interventions implemented.

4. During the beginning shift assessment of a client with asthma who is receiving oxygen via nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?

Correct answer: C

Rationale: Rapid, shallow respirations with intermittent wheezes are concerning as they indicate a potential worsening of the client's asthma. This finding suggests airway narrowing, which can lead to respiratory failure. Immediate intervention is required to address this respiratory distress. A pulse oximetry reading of 89% is low and indicates hypoxemia, but the respiratory pattern described in option C takes priority as it directly reflects the client's respiratory status. Crackles at the base of the lungs suggest fluid accumulation, which is important but not as immediately critical as the respiratory distress in asthma. Excessive thirst and a dry cracked tongue may indicate dehydration, which is relevant but not as urgent as the respiratory compromise presented in option C.

5. The healthcare professional is planning a community health fair. Which of the following topics should be given the highest priority?

Correct answer: A

Rationale: In planning a community health fair, the highest priority should be given to blood pressure screening. This is because hypertension is a common and serious health issue that often goes undetected. Identifying individuals with high blood pressure early can lead to timely interventions and management, potentially preventing severe complications such as heart disease or stroke. While topics like diabetes education, smoking cessation, and nutrition are important, addressing blood pressure screening first aligns with the goal of early detection and prevention of a prevalent health concern.

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