a female client is admitted with a tentative diagnosis of guillain barre syndrome which finding is most important for the nurse to report to the healt
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Nursing Elites

HESI RN

Community Health HESI

1. A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?

Correct answer: B

Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.

2. A client presents at a community-based clinic with complaints of shortness of breath, headache, 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?

Correct answer: D

Rationale: The correct answer is D, carbon monoxide poisoning. This client's symptoms of shortness of breath and headache are consistent with carbon monoxide exposure, which can result from using gasoline-powered equipment in poorly ventilated areas. Asbestos (choice A) is linked to respiratory issues but does not typically present with these acute symptoms. Silica dust (choice B) exposure is associated with lung damage, not the symptoms described. Histoplasmosis (choice C) is a fungal infection and would not typically manifest with the symptoms presented by the client.

3. The healthcare professional is planning a health education workshop for a group of adolescents on the dangers of substance abuse. Which strategy is most likely to be effective?

Correct answer: B

Rationale: Inviting individuals in recovery to share their stories is the most effective strategy for educating adolescents about the dangers of substance abuse. Personal stories have a significant impact as they provide real-life examples of the consequences of substance abuse, making the information more relatable and emotionally engaging. This approach can evoke empathy, create a deeper understanding of the risks involved, and potentially deter adolescents from experimenting with substances. Showing videos of the effects of substance abuse (choice A) may be impactful, but personal narratives often have a stronger emotional connection. Providing statistical data (choice C) may not resonate as strongly with adolescents as personal stories. Distributing brochures (choice D) is informative but may not have the same emotional impact and engagement as hearing firsthand experiences.

4. The healthcare professional is developing a program to educate parents on the importance of immunizations. Which topic should be prioritized?

Correct answer: A

Rationale: Prioritizing the benefits of immunizations is crucial in helping parents comprehend the significance of vaccines in safeguarding their children against preventable diseases. Understanding the positive impact of immunizations can alleviate concerns and misconceptions that parents may have, ultimately encouraging them to make informed decisions regarding their children's health. Discussing potential side effects (choice B) is important but should come after highlighting the benefits to avoid instilling unnecessary fear. While the immunization schedule (choice C) is essential information, it may be overwhelming if presented as the initial focus. Comforting children during vaccinations (choice D) is valuable but secondary to ensuring parents understand the benefits of immunizations.

5. A school nurse is organizing a vaccination clinic for middle school students. Which vaccine is most important for the nurse to include?

Correct answer: B

Rationale: The most important vaccine for the school nurse to include in the vaccination clinic for middle school students is the tetanus, diphtheria, and pertussis (Tdap) vaccine. Tdap is recommended for preteens as part of the routine vaccination schedule to protect against these serious diseases. Hepatitis B, varicella, and MMR vaccines are also important but for this specific age group, Tdap takes precedence to ensure protection against tetanus, diphtheria, and pertussis.

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