An older male client is admitted with the medical diagnosis of a possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side.

When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water.

Which action should the nurse take?

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

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

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

Obtain thickening powder before providing any more fluids.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Ask the wife to stop and assess the client's swallowing reflex. Rationale: While assessing the client's swallowing reflex is important, the immediate priority is to provide hydration and comfort to the client, especially if the client is tearful and attempting to drink water. The nurse should assist the wife in providing small sips of water while being cautious and observing the client's ability to swallow safely.

Choice B rationale:

Give the wife a straw to help facilitate the client's drinking. Rationale: Giving the wife a straw may be helpful, but it does not address the client's immediate need for hydration and assistance with drinking. The nurse should actively assist in providing water to the client while assessing the client's ability to swallow safely.

Choice C rationale:

Assist the wife and carefully give the client small sips of water. Rationale: This is the correct answer. The nurse's immediate priority should be to assist the client with hydration. Providing small sips of water while being cautious and observing the client's ability to swallow safely is an appropriate action. This can help address the client's immediate needs for comfort and hydration.

Choice D rationale:

Obtain thickening powder before providing any more fluids. Rationale: While thickening powder may be necessary for clients with swallowing difficulties, it may cause unnecessary delay in providing hydration to the client in distress. The nurse should first provide water and assess the client's swallowing abilities. If thickened liquids are indicated, they can be administered later as per the healthcare provider's orders.

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Correct Answer is B

Explanation

Choice A rationale:

Drinking electrolyte fluid replacements may be necessary if the client is dehydrated due to diabetic ketoacidosis (DKA). However, addressing the increased thirst, which is a sign of DKA, should involve insulin administration to correct the underlying problem of high blood sugar.

Choice B rationale:

Giving a dose of regular insulin as prescribed is the most appropriate action to address increased thirst in a client with type 1 diabetes and early signs of DKA. Elevated blood sugar levels are the cause of the increased thirst, and insulin helps lower blood sugar levels.

Choice C rationale:

Resuming normal physical activity may not be advisable when a client is experiencing early signs of DKA. Strenuous physical activity can exacerbate hyperglycemia, and the primary focus should be on insulin administration and rehydration.

Choice D rationale:

Measuring urine output over the next 24 hours is important for monitoring hydration status in a client with DKA. However, the immediate priority is to address the increased thirst and hyperglycemia with insulin therapy.

A. Neurology unit supervisor. B. Adult nurse practitioner. C. Nurse case manager. D. Risk management nurse.

Correct Answer is C

Explanation

Choice A rationale:

The neurology unit supervisor is not the most appropriate nurse to coordinate the progression of care for a client with a spinal cord injury (SCI). While they may have expertise in neurology, the nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including SCI. They can facilitate communication between various healthcare providers and ensure that the client receives comprehensive care throughout their stay.

Choice B rationale:

An adult nurse practitioner may have specialized knowledge in the care of adults, but they may not have the specific skills and training required to coordinate the care of a client with a spinal cord injury in the ICU. Nurse case managers are better equipped to manage complex cases and ensure the continuity of care for the client.

Choice D rationale:

A risk management nurse focuses on minimizing healthcare-related risks and ensuring the safety of patients and staff. While their role is essential, it is not the primary responsibility to coordinate the progression of care for a client with a spinal cord injury. The nurse case manager is better suited for this role as they specialize in care coordination.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Correct Answer is B

Explanation

A client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Correct Answer is C

Explanation

The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?

A nurse is caring for a client with a specific phobia. Which statement by the nurse is accurate regarding phobias?

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

A client with a long history of migraine headaches asks the nurse if there are non-pharmaceutical ways to help obtain pain relief. Which intervention should the nurse offer?

Patient Data. Exhibits The nurse has called the physician and is anticipating orders. Select the actions that would help with the listed treatment goals. Select all that apply.