while caring for a child with reyes syndrome the nurse should give which action the highest priority
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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 evaluating your client's level of wellness, which of the following indicators can you see?

Correct answer: C

Rationale: When evaluating a client's level of wellness, indicators such as appropriate nutritional level, sense of personal security, and acceptance of oneself and one's limitations are crucial. Option C, 'Acceptance of oneself and one's limitations,' directly relates to mental wellness and self-awareness, making it a key indicator of overall well-being. Options A, B, and D are not as directly tied to the psychological and emotional aspects of wellness, making them less relevant indicators in this context. Therefore, the correct answer is C.

3. What is the term for a learning process whereby knowledge, attitudes, and practice of people are changed to improve the health status of individuals, families, or communities?

Correct answer: D

Rationale: Health education is the correct term for the learning process that involves changing knowledge, attitudes, and practices to enhance health status. Choice A, 'Motivating,' is incorrect as it refers to inspiring action rather than the educational aspect. Choice B, 'Counseling,' focuses on providing guidance and support rather than specifically targeting knowledge and practice changes. Choice C, 'Disease prevention,' is related to strategies aimed at avoiding the occurrence of illnesses rather than the broader concept of educating for overall health improvement.

4. The RN is making a home visit to a female client with end-stage heart disease. She has a living will and states she will never go back to the hospital. During the visit, the RN notes that the client is pale and SOB while speaking. The RN discovers 3+ edema in both ankles and bilateral pulmonary crackles. Which intervention should the RN implement first?

Correct answer: B

Rationale: Obtaining a peripheral O2 saturation reading is the priority intervention in this scenario. It helps assess the client's oxygenation status quickly, which is crucial in a client with signs of respiratory distress, such as shortness of breath and bilateral pulmonary crackles. Ordering a chest X-ray (Choice A) may be necessary later but does not address the immediate need for oxygen assessment. Obtaining an order for a complete blood count (Choice C) is not the priority in this situation as it does not directly address the client's respiratory distress. Instructing the patient to stay in bed (Choice D) does not address the underlying issue of potential hypoxia and respiratory compromise.

5. Which family planning method is not advisable for women with extremely irregular menstrual periods?

Correct answer: C

Rationale: Natural family planning relies on tracking menstrual cycles to determine fertile days for avoiding or achieving pregnancy. It may not be suitable for women with extremely irregular menstrual periods as it can be challenging to predict fertile days accurately. Oral contraceptives (A), diaphragms (B), and vaginal contraceptives (D) do not rely on regular menstrual cycles for their effectiveness, making them more suitable options for women with irregular periods.

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