A client experiencing a sudden onset of confusion and trouble speaking at home is transported to the emergency department. The client does not understand simple commands and appears very frustrated. Which intervention should the nurse perform in the immediate management of the client?

Test for a swallowing reflex and perform communication deficit assessments.

Administer aspirin to prevent further clot formation and platelet clumping

Initiate bilateral intermittent sequential pneumatic compression devices.

Determine when symptoms began and if improved or worsened since onset.

Answer and Explanation

The Correct Answer is D

D. Assessing the time of symptom onset and determining if the symptoms have improved or worsened since onset is crucial for determining the urgency of the situation and guiding further management. This information helps the healthcare team identify the potential cause of the symptoms and decide on the appropriate course of action. Sudden onset of confusion and trouble speaking can be indicative of various serious conditions such as stroke, transient ischemic attack (TIA), intracranial hemorrhage, or other neurological emergencies.
A. Assessing for a swallowing reflex and performing communication deficit assessments are important aspects of the client's assessment but they may not be the immediate priority in the initial management of the client.
B. Administering aspirin to prevent further clot formation and platelet clumping may be appropriate if the client is suspected to have an ischemic stroke, but it should be done based on a comprehensive assessment
C. Initiating bilateral intermittent sequential pneumatic compression devices is indicated for preventing deep vein thrombosis (DVT) in hospitalized clients, but it is not the most immediate intervention for this particular client.

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Free Nursing Study Resources

Correct Answer is ["A","C","G"]

Explanation

A. Regular physical activity is a cornerstone of prediabetes management. Exercise helps improve insulin sensitivity, promotes weight loss, and reduces the risk of progression to type 2 diabetes.
C. Weight reduction is an essential component of prediabetes management, especially for individuals who are overweight or obese. Losing as little as 5-10% of body weight can significantly improve insulin sensitivity and reduce the risk of developing type 2 diabetes.
G. Nutrition education: Nutrition education is a crucial component of prediabetes management. Providing education on healthy eating habits, portion control, carbohydrate counting, and making nutritious food choices can empower individuals with prediabetes to make positive dietary changes that support blood sugar control and overall health.
B. Short-acting insulin is not typically used in the treatment of prediabetes. Insulin therapy is usually reserved for individuals with type 1 diabetes or advanced type 2 diabetes who cannot adequately control blood sugar levels with oral medications or lifestyle interventions.
D. While oral antidiabetic medications may be prescribed for individuals with type 2 diabetes, they are not typically used as first-line therapy for prediabetes. Lifestyle modifications, such as diet and exercise, are usually the primary approach for managing prediabetes.
E. Individuals with prediabetes should generally aim to moderate their carbohydrate intake, particularly refined carbohydrates and added sugars, to help improve blood sugar control and reduce the risk of developing type 2 diabetes.
F. Similar to short-acting insulin, long-acting insulin is not typically used in the treatment of prediabetes. Insulin therapy is generally reserved for individuals with type 1 diabetes or advanced type 2 diabetes who require insulin to control blood sugar levels.

A. Sitting upright B. Tightness in the chest C. Medication compliance D. Respirations of 28 breaths/minute E. Restlessness F. Dyspnea G. Pulse oxygenation of 85%

Correct Answer is ["A","B","D","E","F","G"]

Explanation

A. Patients with respiratory distress often prefer to sit upright or in a tripod position to ease breathing by allowing maximal lung expansion. Sitting upright helps relieve pressure on the diaphragm and allows better air exchange in the lungs.
B. Chest tightness is a common symptom of various respiratory conditions, such as asthma, chronic obstructive pulmonary disease (COPD), or pneumonia. It can result from bronchoconstriction, inflammation, or accumulation of mucus in the airways, leading to difficulty breathing.
D. An increased respiratory rate (tachypnea) may indicate respiratory distress or difficulty breathing. Tachypnea is a compensatory mechanism to increase oxygen intake or remove carbon dioxide from the body when lung function is compromised.
E. Restlessness can be a cue for a respiratory problem. Patients experiencing respiratory distress may exhibit restlessness due to hypoxia (low oxygen levels), discomfort, or anxiety related to difficulty breathing.
F. Dyspnea, or shortness of breath, is a significant cue for a respiratory problem. It is a common symptom of various respiratory conditions, including asthma, COPD, pneumonia, and pulmonary embolism. Dyspnea may range from mild to severe and can significantly impact the patient's quality of life and functional status.
G. A pulse oxygenation level of 85% indicates hypoxemia (low blood oxygen levels) and is a significant cue for a respiratory problem. Hypoxemia can result from various respiratory conditions or inadequate ventilation and may lead to tissue hypoxia and organ dysfunction if left untreated.
C. Medication compliance is not directly indicative of a respiratory problem. However, it may be relevant to managing respiratory conditions if the patient requires medications such as bronchodilators or corticosteroids to control symptoms or prevent exacerbations.
H. While an elevated heart rate (tachycardia) can be associated with respiratory distress, it is not specific to respiratory problems and may occur in response to other stressors or medical conditions.
I. Body mass index (BMI) is a measure of body fat based on height and weight and is not directly indicative of a respiratory problem. However, obesity is a risk factor for respiratory conditions such as obstructive sleep apnea and obesity hypoventilation syndrome.

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A client experiencing a sudden onset of confusion and trouble speaking at home is transported to the emergency department. The client does not understand simple commands and appears very frustrated. Which intervention should the nurse perform in the immediate management of the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Review Hand P and laboratory results Exhibits What item(s) should be included in the treatment regimen for this client? Select all that apply.

Correct Answer is ["A","C","G"]

Explanation

Patient Data Exhibits What finding(s) are cues for a respiratory problem? Select all that apply.

Correct Answer is ["A","B","D","E","F","G"]

Explanation

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