A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

Assess the client's bilateral hand grasp strength.

Place a padded tongue blade at the client's bedside.

Check the client's bedside glucose level.

Administer flumazenil IV per facility policy to the client.

Answer and Explanation

The Correct Answer is A

A. Assess the client's bilateral hand grasp strength: Slurred speech in a client with sickle cell crisis raises concern for stroke due to vaso-occlusion in cerebral vessels. Assessing hand grasp strength helps evaluate for unilateral weakness, a key indicator of stroke, necessitating immediate intervention.

B. Place a padded tongue blade at the client's bedside: There is no indication the client is experiencing a seizure. Seizure precautions are not a priority unless additional neurological symptoms suggest seizure activity.

C. Check the client's bedside glucose level: Hypoglycemia can cause slurred speech, but in a client with sickle cell disease, stroke is a more likely cause. Assessing neurological function should take precedence over checking glucose unless the client has a history of diabetes or other risk factors.

D. Administer flumazenil IV per facility policy to the client: Flumazenil is used to reverse benzodiazepine overdose. There is no indication that the client has received benzodiazepines or is experiencing medication toxicity.

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Correct Answer is A

Explanation

A. "I will hold my cellphone on the opposite side of the pacemaker.": Cellphones emit electromagnetic signals that can interfere with pacemaker function if held directly over the device. Keeping the phone on the opposite side minimizes the risk of interference and ensures proper pacemaker function.

B. "I can resume physical activity within 2 weeks.": Strenuous physical activity should be avoided for about 4-6 weeks to allow proper healing of the pacemaker site. Early resumption of activity can lead to lead dislodgement or complications.

C. "I need to cover my pacemaker with a dressing when I shower.": After the initial post-procedure period, there is no need to keep the pacemaker site covered while showering. The incision should be kept dry until it fully heals, but a permanent dressing is unnecessary.

D. "I should avoid using a microwave oven.": Modern pacemakers are shielded against microwave interference, making it safe to use a microwave. This is a common misconception, as older pacemakers were more susceptible to electrical interference.

A. Born with a high birth weight B. Frequent exposure to low-volume noise C. Use of a loop diuretic D. Chronic infections of the middle ear E. Perforation of the eardrum

Correct Answer is ["C","D","E"]

Explanation

A. Born with a high birth weight: Hearing loss is more commonly associated with low birth weight rather than high birth weight. Premature infants or those with complications like neonatal hypoxia are at a greater risk of auditory damage due to underdeveloped structures and increased vulnerability to infections.

B. Frequent exposure to low-volume noise: Prolonged exposure to loud noise, not low-volume noise, is a significant risk factor for hearing loss. High-decibel sounds can cause permanent damage to the cochlear hair cells, leading to sensorineural hearing loss, especially in occupational or recreational settings.

C. Use of a loop diuretic: Loop diuretics like furosemide can be ototoxic, especially when administered in high doses or given too rapidly through IV. They can cause reversible or permanent hearing loss by damaging the stria vascularis of the cochlea, which affects inner ear fluid balance.

D. Chronic infections of the middle ear: Recurrent otitis media can lead to chronic inflammation, scarring, or ossicle damage, resulting in conductive hearing loss. Long-term infections may also cause cholesteatoma formation, which can further impair hearing by destroying middle ear structures.

E. Perforation of the eardrum: Tympanic membrane rupture due to infections, trauma, or barotrauma can lead to conductive hearing loss by impairing sound transmission. While small perforations may heal spontaneously, larger tears might require surgical repair to restore normal hearing function.

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A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

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