The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.
The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?
Keep the bed in the lowest position and initiate seizure and fall precautions.
Place an indwelling urinary catheter and measure strict intake and output.
Maintain elevated positioning of the dependent joints on affected side.
Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
The Correct Answer is D
Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.
Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.
Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A is correct because a quiet, non-stimulating environment can help reduce the agitation, confusion, and hallucinations that are common in alcohol withdrawal delirium. The nurse should also provide reassurance, orientation, and safety measures to the client.
Choice B is incorrect because forcing oral fluids and providing frequent small meals are not the most important interventions for a client with alcohol withdrawal delirium. The client may have difficulty swallowing, nausea, vomiting, or diarrhea that can interfere with oral intake. The nurse should monitor the client's hydration and nutrition status and provide intravenous fluids or supplements as needed.
Choice C is incorrect because confronting the client's denial of substance abuse is not the most important intervention for a client with alcohol withdrawal delirium. The client may not be able to comprehend or accept the reality of their situation due to their altered mental state. The nurse should avoid arguing or challenging the client and focus on providing supportive care.
Choice D is incorrect because encouraging attendance and group participation are not the most important interventions for a client with alcohol withdrawal delirium. The client may not be able to participate in group activities due to their severe withdrawal symptoms and may need individualized care. The nurse should facilitate referrals to appropriate resources for substance abuse treatment when the client is stable and ready.
Correct Answer is B
Explanation
Choice A: A 14-year-old client with anorexia nervosa refusing to eat the evening snack is a concern, but it’s not an immediate threat. The nurse can address this issue after dealing with more urgent situations.
Choice B: An 18-year-old client with antisocial behavior being yelled at by other clients requires immediate attention. This situation can escalate quickly and may lead to physical harm or emotional distress for the client.
Choice C: A 16-year-old client diagnosed with major depression refusing to participate in group is a concern, but it’s not an immediate threat. The nurse can address this issue after dealing with more urgent situations.
Choice D: A 17-year-old client diagnosed with bipolar disorder pacing around the lobby might be experiencing agitation or restlessness, but unless they’re showing signs of immediate distress or posing a risk to themselves or others, it’s not the most urgent situation.
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