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. A client with a history of seizures is receiving phenytoin (Dilantin). The nurse should monitor the client for which of the following side effects?

Correct answer: C

Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.

3. The nurse is caring for a client with status epilepticus. The most important nursing assessment of this client is

Correct answer: B

Rationale: In status epilepticus, the most crucial nursing assessment is the level of consciousness. Assessing the client's level of consciousness is vital as prolonged seizures can result in hypoxia, brain damage, and require immediate intervention. Pulse and respirations (choice C) are important assessments, but in status epilepticus, the priority is to monitor the client's neurological status. Checking intravenous fluid infusion (choice A) and extremities for injuries (choice D) are not the primary assessments needed in managing a client experiencing status epilepticus.

4. Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?

Correct answer: A

Rationale: Sports and games with rules are appropriate for the cognitive development stage of 7-year-olds.

5. The nurse is teaching a community group about risks of cardiovascular disease. Several clients ask the nurse to determine their risk. Which client should the nurse identify as having the greatest risk for cardiovascular disease?

Correct answer: C

Rationale: The correct answer is C. A male with a high LDL level (200 mg/dl) has a significant risk for cardiovascular disease. High levels of LDL cholesterol are associated with an increased risk of atherosclerosis and heart disease. Choices A, B, and D have serum cholesterol levels that are slightly elevated but are not as specific or directly linked to cardiovascular risk as high LDL levels. Therefore, the client with the high LDL level is at the greatest risk for cardiovascular disease.

Similar Questions

The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?
A 4-month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78; respirations 28, and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
What are the sources of information about the family?
This refers to trained community health workers or health auxiliary volunteers:
In which of the following settings would a community health nurse be less likely to be involved?

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