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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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.

A. Increase physical activity. B. Take vitamin supplements. C. Consume a high protein diet. D. Obtain a prostate-specific antigen blood level test.

Correct Answer is A

Explanation

A. Physical activity helps maintain overall health, including cardiovascular fitness, weight management, and hormonal balance, which may contribute to reducing the risk of BPH development or progression.
B. There is limited evidence to support their role in preventing or reducing the risk of BPH
C. Dietary factors such as overall calorie intake, fat consumption, and specific food choices may play a role in prostate health, but the relationship between protein intake and BPH risk is not well- established.
D. PSA testing is used for screening and monitoring prostate cancer, not BPH.

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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

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

A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?

Correct Answer is A

Explanation

The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

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