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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Thalassemia: A genetic blood disorder affecting hemoglobin production. While patients with severe anemia may have an increased bleeding risk, thalassemia itself is not a contraindication to heparin. Caution is needed if the patient has splenomegaly or significant anemia.
B. Rheumatoid arthritis: An autoimmune condition that can increase bleeding risk due to chronic inflammation and medication use, such as NSAIDs or corticosteroids. However, heparin is not contraindicated unless there is an associated bleeding disorder or severe thrombocytopenia.
C. Thrombocytopenia: A condition characterized by a low platelet count, significantly increasing the risk of bleeding. Heparin use can worsen this condition, especially in cases of heparin-induced thrombocytopenia (HIT), which can lead to both bleeding and thrombosis.
D. COPD: A chronic lung disease that does not directly contraindicate heparin therapy. While COPD patients may be at risk for deep vein thrombosis due to immobility, heparin remains a standard prophylactic treatment unless there are other bleeding risks.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Diabetes:
• Weight
• Blood glucose
Pancreatitis:
• None
Hyperthyroidism:
• Heart rate
• T3 level
Rationale:
• Weight: The client has experienced unintended weight loss, which is a common symptom of diabetes due to the body's inability to use glucose effectively, leading to fat and muscle breakdown.
• Heart rate: Tachycardia is a hallmark of hyperthyroidism due to increased metabolic activity and sympathetic nervous system stimulation.
• T3 level: The T3 level is within the normal range but on the higher end, which can still support hyperthyroidism when considered with other clinical findings.
• Blood glucose: An elevated blood glucose level of 250 mg/dL is consistent with diabetes, as normal fasting levels are below 106 mg/dL.
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