A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?
Hold the client's evening dose of digoxin.
Increase the client's fluid intake.
Complete a neurological check.
Administer the prescribed PRN antihypertensive medication.
Administer the prescribed PRN antihypertensive medication.
The Correct Answer is C
A. Holding the client's evening dose of digoxin is not the priority at this time. The client's symptoms of confusion and drowsiness require immediate attention to determine the cause.
B. Increasing the client's fluid intake may be important for various reasons, but it is not the most urgent action in this situation. The client's altered mental status and vital signs need to be assessed first.
C. Completing a neurological check is the most appropriate action in this situation. The sudden onset of confusion and drowsiness may indicate a neurological issue that needs to be assessed promptly. This includes assessing the client's level of consciousness, pupillary response, motor function, and other neurological signs.
D. Administering the prescribed PRN antihypertensive medication is not indicated based on the client's current presentation. The client's symptoms are more suggestive of a neurological issue rather than hypertension. It's important to address the altered mental status first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Initiative vs. guilt is the developmental stage for children aged 3 to 6 years, where they begin to assert control and power over their environment. This stage is not applicable for a 9-year-old child.
B. Autonomy vs. shame and doubt is relevant for children aged 1 to 3 years. This stage focuses on children developing a sense of personal control over physical skills and a sense of independence, which is not directly relevant to a 9-year-old.
C. Identity vs. role confusion typically applies to adolescents aged 12 to 18 years, where individuals explore their independence and develop a sense of self and personal identity, making it less relevant for a 9-year-old child.
D. Industry vs. inferiority is the stage for children aged 6 to 12 years, where they develop a sense of pride in their accomplishments and abilities. During this stage, children are learning to cope with new social and academic demands, making it essential for the nurse to consider the child's self-esteem and competence in managing their asthma and engaging in age-appropriate activities. This stage directly relates to the planning of home care for the 9-year-old child with asthma.
Correct Answer is A
Explanation
A. Determining the location of the pain is the first step in assessing and managing a client's pain. It helps the nurse gather important information about the nature and potential causes of the pain.
B. Administering the medication may be necessary, but it should come after the nurse has assessed the location and characteristics of the pain to ensure the correct medication and dosage are given.
C. Repositioning the client can be important for comfort and pain relief, but it should come after the nurse has assessed the location of the pain to determine the best position for the client.
D. Reviewing the effects of the pain medication is important, but it should come after the nurse has administered the medication. It is essential to first address the client's request for pain relief by assessing the pain location and administering the appropriate
medication.
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