A nurse is preparing to insert a nasogastric tube in a client. Which of the following actions should the nurse take?

Rationale:

A. Swelling of the lips: Swelling of the lips can be an early sign of anaphylaxis, a severe allergic reaction. Epinephrine is the first-line treatment for anaphylaxis because it rapidly reduces airway swelling, improves breathing, and supports blood pressure by constricting blood vessels.

B. Nausea: While nausea may occur during an allergic reaction, it is not a primary life-threatening symptom addressed by epinephrine. Epinephrine targets cardiovascular and respiratory symptoms more directly, not gastrointestinal discomfort.

C. Hand tremors: Tremors are actually a potential side effect of epinephrine due to its stimulation of the sympathetic nervous system. The medication is not intended to treat tremors and may even cause or worsen them temporarily.

D. Hyperglycemia: Epinephrine can increase blood glucose levels as a side effect, but it is not prescribed to treat or manage hyperglycemia. Managing blood glucose is not part of the therapeutic purpose of this emergency medication.

Rationale:

A. "What coping methods help you when you feel bad?": While assessing coping mechanisms is important for long-term care planning, it does not immediately address the client's current risk for self-harm or suicide. This question is more appropriate after ensuring the client's safety.

B. "Do you have thoughts of suicide?": Determining if the client has suicidal ideation is the priority in this situation. Clients who self-harm may be at high risk for suicide, and direct questioning helps assess intent, plan, and urgency, which is crucial for ensuring immediate safety.

C. "Tell me why you hurt yourself.": Exploring the reasons behind self-injury can be valuable later during therapy or assessment, but it is not the first priority. The nurse must first evaluate the client’s current mental state and risk for further harm before exploring motives.

D. "Who can we call to support you?": Identifying a support system is important for discharge planning and ongoing therapy, but it does not address the immediate concern of suicide risk. Ensuring the client's current safety takes precedence over external support at the time of admission.