a hospitalized child suddenly has a seizure while his family is visiting the nurse notes whole body rigidity followed by general jerking movements the
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Nursing Elites

HESI LPN

Community Health HESI Exam

1. A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is

Correct answer: D

Rationale: Risk for aspiration is a priority concern following a seizure, especially when the child vomits, as there is a danger of aspirating the vomit into the lungs, leading to respiratory complications. The other options are not the priority in this situation. While infection risk and fluid volume deficit are important, ensuring the child's airway is clear and there is no risk of aspiration takes precedence. Altered family processes may be a concern but addressing the immediate physiological risk is the priority.

2. What does the term 'social determinants of health' refer to?

Correct answer: C

Rationale: The term 'social determinants of health' refers to the conditions in which people are born, grow, live, work, and age. This includes factors like socioeconomic status, education, physical environment, employment, and social support networks. These factors have a significant impact on health outcomes. Choices A, B, and D are incorrect because genetic predispositions, lifestyle choices, and access to medical care, although important, are not encompassed by the term 'social determinants of health.'

3. The family health care plan includes the following listed in sequence:

Correct answer: D

Rationale: In a family health care plan, the correct sequence should start with identifying the problems (statement of the problems), setting objectives, planning interventions, and then evaluating the outcomes. This sequence ensures a logical and structured approach to healthcare planning. Choices A, B, and C are incorrect as they do not follow the logical order of healthcare planning steps.

4. A client with a urinary tract infection is receiving ciprofloxacin (Cipro). The nurse should monitor the client for which of the following side effects?

Correct answer: D

Rationale: Ciprofloxacin can cause tendonitis and an increased risk of tendon rupture. Monitoring for tendonitis is crucial as it can lead to significant musculoskeletal issues. Choices A, B, and C are incorrect as hypertension, hypoglycemia, and hyperkalemia are not typically associated with ciprofloxacin use.

5. What is the main focus of secondary prevention?

Correct answer: A

Rationale: The main focus of secondary prevention is early detection and treatment of disease. This approach aims to identify health conditions in their early stages when they are easier to treat or manage effectively. Choice B, rehabilitation, is more aligned with restoring function after an illness or injury has occurred. Choice C, health promotion, concentrates on educating and empowering individuals to adopt healthy behaviors to prevent the onset of diseases. Choice D, palliative care, is focused on providing comfort and improving the quality of life for individuals with serious illnesses or at the end of life, rather than on early detection and treatment.

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