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. Diminished breath sounds: A pneumothorax occurs when air accumulates in the pleural space, leading to lung collapse. This results in reduced air entry, causing diminished or absent breath sounds on the affected side. Other symptoms may include dyspnea, tachypnea, and chest pain.

B. Distended neck veins: Neck vein distention is more commonly associated with conditions such as cardiac tamponade or superior vena cava syndrome. A pneumothorax typically causes respiratory distress rather than venous congestion. If a tension pneumothorax develops, neck vein distention may occur, but it is not an early or primary sign.

C. Irregular heart rate: While severe cases of pneumothorax can cause cardiovascular compromise due to pressure on the heart and great vessels, an irregular heart rate is not a direct or early indicator. Cardiac arrhythmias are more often seen with electrolyte imbalances, cardiac ischemia, or other primary heart conditions.

D. Itching over the incision: Itching at the catheter insertion site is a common postoperative reaction, often related to healing, adhesive irritation, or mild inflammation. It is not indicative of a pneumothorax, which primarily presents with respiratory distress and absent or diminished breath sounds.

A. Provide a diet of fresh fruits and vegetables for the client. B. Apply new gloves when alternating between wound care sites. C. Clean the equipment in the client's room once per week. D. Limit visitation time for the client's children to 40 min per day.

Correct Answer is B

Explanation

A. Provide a diet of fresh fruits and vegetables for the client: While a high-protein, high-calorie diet is essential for wound healing in burn patients, fresh fruits and vegetables may not be appropriate if the client is immunocompromised due to the risk of bacterial contamination. Cooked or peeled produce is often recommended.

B. Apply new gloves when alternating between wound care sites: Burn wounds are highly susceptible to infection. Changing gloves between different wound sites prevents cross-contamination and reduces the risk of spreading bacteria, which is critical in preventing wound infections and sepsis.

C. Clean the equipment in the client's room once per week: Equipment in a burn unit should be cleaned and disinfected daily to minimize the risk of infection. Weekly cleaning is insufficient for infection control in an immunocompromised client.

D. Limit visitation time for the client's children to 40 min per day: While infection control is a priority, limiting visitation is not typically necessary unless the visitors are ill. Emotional support from family can aid in psychological recovery, and proper infection control measures can be implemented without strict visitation limits.

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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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