A client with delusions tells the nurse, "You aren't doing your job.
Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

The correct answer is choice c. Ensure that the call bell is easily accessible to the client.

Choice A rationale:

Reassuring the client that someone will check on him hourly is supportive but does not directly address the immediate need for the client to call for assistance if he needs to use the bathroom during the night.

Choice B rationale:

Placing fresh water and a glass within reach is helpful for hydration but may increase the need to urinate, which could exacerbate the issue of urinary frequency at night.

Choice C rationale:

Ensuring that the call bell is easily accessible allows the client to quickly and safely request assistance if he needs to use the bathroom, reducing the risk of falls and ensuring timely help.

Choice D rationale:

Offering an evening snack before providing oral care is a good practice for comfort and nutrition but does not directly address the issue of urinary frequency or the need for nighttime assistance.

Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of Stroke as evidenced by Neurological defects and Garbled speech. The symptoms of facial drooping, garbled speech, and high blood pressure are common signs of a stroke. However, it’s important to get a professional medical diagnosis as soon as possible. Please seek immediate medical attention.

Choice A rationale:

Intoxication is a plausible explanation for the client’s symptoms, especially given the report of alcohol consumption. However, intoxication typically does not cause facial drooping, which is a common sign of neurological issues such as a stroke. Therefore, while intoxication may contribute to the client’s condition, it is not the most likely primary cause.

Choice B rationale:

Stroke is a medical emergency that often presents with facial drooping and garbled speech, both of which are observed in this client. A stroke occurs when blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. This can lead to brain cells dying in minutes. The client’s high blood pressure (210/98 mm Hg) is a significant risk factor for stroke. Normal blood pressure ranges from 90/60 mm Hg to 120/80 mm Hg.

Choice C rationale:

An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation.

Choice D rationale:

Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.