An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?

Obtain thickening powder before providing any more fluids.

Assist the spouse and carefully give the client small sips of water.

Ask the spouse to stop and assess the client's swallowing reflex.

Give the spouse a straw to help facilitate the client's drinking.

Answer and Explanation

The Correct Answer is C

Rationale

A. Thickening powder is used to modify the consistency of liquids to prevent aspiration in clients with swallowing difficulties. This option suggests ensuring safety by thickening fluids to reduce the risk of choking or aspiration. However, this does not address the underlying issue.

B. This option involves immediate action to provide hydration under close supervision. It implies that the nurse will closely monitor the client's ability to swallow and assess for signs of aspiration during the process. However, it does not address the underlying risk.

C. This option focuses on assessing the client's ability to swallow before providing more fluids. It acknowledges the potential danger of giving fluids without knowing the client's current swallowing ability, which could lead to aspiration.

D. Providing a straw might seem helpful but could potentially increase the risk of aspiration if the client has swallowing difficulties. It does not address the immediate need for assessing the client's ability to swallow safely.

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Correct Answer is B

Explanation

Rationale

A. Diarrhea and flatulence are common gastrointestinal side effects of statin medications like lovastatin. While uncomfortable for the client, these symptoms are typically not serious and do not require immediate follow-up unless severe or persistent.

B. Muscle pain, also known as myalgia, is a potential side effect of statin therapy. In some cases, statins can cause muscle inflammation (myositis) or more severe muscle breakdown (rhabdomyolysis), which can lead to serious complications such as kidney damage. If a client reports new or worsening muscle pain, especially if accompanied by weakness, tenderness, or dark urine, it requires immediate follow-up to assess for these potential complications.

C. Abdominal cramps can occur as a gastrointestinal side effect of statins but are generally not considered a serious adverse reaction. They may improve with time or adjustments in diet or medication administration timing.

D. Altered taste, such as a metallic taste, is a less common side effect of statin therapy. While it can be bothersome, it is usually not serious and does not typically require immediate follow-up unless severe or persistent.

A. "I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best." B. "I never use the inhaler unless I am feeling really short of breath." C. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away." D. "I always shake the inhaler several times before I start."

Correct Answer is C

Explanation

Rationale

A. This comment suggests that the client is aware of the correct technique (inhaling and holding breath) but finds it difficult to execute properly. It indicates a partial understanding of the inhaler technique but potential difficulty in coordination.

B. This comment indicates a misunderstanding of the purpose of a rescue inhaler. Rescue inhalers are intended to be used promptly at the onset of symptoms to relieve acute shortness of breath. Delaying use until symptoms are severe may result in inadequate relief and worsening of respiratory distress.

C. This comment suggests that the client may be swallowing the medication instead of inhaling it into the lungs. Inhalers are meant to deliver medication directly into the lungs through inhalation, not swallowing. Swallowing the medication can lead to gastrointestinal side effects like nausea.

D. Shaking the inhaler before use is a correct step to ensure proper dispersion of the medication. This comment indicates the client understands and follows this part of the inhaler technique correctly.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

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A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

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