a 6 year old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears the nurse suspec
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Nursing Elites

HESI RN

Community Health HESI

1. A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with the basilar skull fracture?

Correct answer: D

Rationale: The correct answer is D: Rhinorrhea or otorrhea with halo sign. Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear) are signs of a basilar skull fracture, indicating the need to assess for possible meningeal tears that manifest as a halo sign with cerebrospinal fluid (CSF) leakage from the ears or nose. Choices A, B, and C are incorrect because blurred vision, shoulder pain, and abdominal pain are not typically associated with a basilar skull fracture.

2. A client with a history of coronary artery disease is admitted with chest pain. Which assessment finding requires immediate intervention?

Correct answer: D

Rationale: Chest pain radiating to the left arm is a classic symptom of a myocardial infarction (heart attack) in individuals with coronary artery disease. This finding indicates that the heart muscle may not be receiving adequate oxygen, which requires immediate intervention to prevent further damage or complications. The other assessment findings (heart rate of 90 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 130/80 mm Hg) are within normal limits and do not suggest an acute, life-threatening condition like myocardial infarction.

3. A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse document as health risk factors for the client? (Select all that apply)

Correct answer: D

Rationale: All these factors - age, school dropout, drug addiction - are significant health risk factors for the client. Being young, a high school dropout, and struggling with drug addiction can lead to various complications during pregnancy, such as poor prenatal outcomes and social challenges. These factors can impact the client's overall health and well-being, highlighting the importance of addressing them during prenatal care.

4. A teenage boy with a history of recurring atopic dermatitis (eczema) tells the school nurse that he wants to play high school football. Which action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to advise the teenager to shower with a non-perfumed soap immediately after practice. This recommendation can help reduce the risk of eczema flare-ups by removing sweat and irritants from the skin. Choice A is incorrect as it does not address the specific concerns related to eczema and football. Choice B, notifying the parents of perspiration problems, is not as direct as instructing the teenager on proper skincare. Choice D, informing the football coach, is not the most immediate and relevant action to address the teenager's individual needs.

5. A community health nurse is applying for a federal grant to support a smoking cessation educational program. In which order should the nurse prioritize these nursing activities? Arrange in order top to bottom.

Correct answer: D

Rationale: The correct answer is 'D' - All of the above. The nurse should first determine the target aggregate that will be served by the program to understand the specific population in need. Subsequently, they should consider the pros and cons of different methods of data gathering to ensure the most appropriate data collection strategies are employed. Finally, selecting and training the data collection personnel is essential for the successful implementation of the program. These steps provide a logical progression from identifying the target group to analyzing the collected data. Choices A, B, and C are all crucial steps that must be taken in sequence to effectively develop and implement the smoking cessation educational program.

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