the nurse is caring for an acutely ill 10 year old client which of the following assessments would require the nurses immediate attention
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Community Health HESI Questions

1. The nurse is caring for an acutely ill 10-year-old client. Which of the following assessments would require the nurse's immediate attention?

Correct answer: D

Rationale: The correct answer is D, slow, irregular respirations. In an acutely ill child, this assessment can indicate impending respiratory failure or neurological compromise, necessitating immediate intervention. Rapid bounding pulse (choice A) may indicate tachycardia but is not as immediately concerning as compromised respirations. A temperature of 38.5 degrees Celsius (choice B) is elevated but may not be the most urgent concern unless accompanied by other symptoms. Profuse diaphoresis (choice C) can indicate increased sympathetic activity but is not as critical as respiratory compromise.

2. A male client is brought to the emergency department as the result of a motorcycle accident. He was not wearing a helmet at the time of the accident and states that he has no intention of ever wearing one. Within the framework of the Transtheoretical Model (TTM), which response should the nurse provide?

Correct answer: C

Rationale: Providing information on safety aligns with the TTM framework.

3. An example of individual influences on health status would be:

Correct answer: D

Rationale: The correct answer is 'D' because all the listed factors - cigarette smoking, a parent with adult-onset diabetes, and exposure to toxic substances in the workplace - can individually influence a person's health status. Cigarette smoking directly impacts health by increasing the risk of various diseases. Having a parent with adult-onset diabetes can also influence one's health due to genetic predisposition and lifestyle factors. Exposure to toxic substances in the workplace can lead to health issues. Choices A, B, and C are not mutually exclusive but rather represent different aspects of individual influences on health status, making 'D' the most comprehensive and accurate answer.

4. What does the acronym ICD stand for in medical terminology?

Correct answer: A

Rationale: The correct answer is A: International Classification of Diseases. The ICD is a system used worldwide to classify and code various health conditions and diseases. This system helps in standardizing the documentation and coding of diseases, which is essential for epidemiology, research, and healthcare management. Choices B, C, and D are incorrect as they do not represent the widely recognized meaning of the acronym ICD in medical terminology.

5. While discussing the science of nursing, the nurse identifies the domain of nursing theory. Which linkages should the nurse provide to describe nursing's paradigm?

Correct answer: A

Rationale: The correct answer is A: 'The person, the environment or situation, and health.' In nursing theory, the paradigm includes these core components: the person receiving care, the environment or situation influencing care, and the goal of achieving optimal health outcomes. Choices B, C, and D are incorrect as they do not align with the fundamental aspects of nursing theory and its paradigm.

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