Four days after exposure to the coronavirus (COVID-19), a client has a negative COVID-19 test result.

Eight days after the negative test result, the client presents with fever, fatigue, and cough, and the nurse performs a second COVID-19 test.

Which action is most important for the nurse to take?

Choice B rationale:

Stroke is a condition that occurs when the blood supply to a part of the brain is interrupted, causing brain tissue damage. Facial drooping and garbled speech are common signs of stroke, especially if they occur suddenly and on one side of the face.Stroke is a medical emergency that requires immediate treatment to prevent further brain damage and complications

Choice C rationale:

An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation.

Choice D rationale:

Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.

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.