The nurse observes a client drooling during mealtime. The client complains that his tongue feels swollen, and his jaw feels tight. What is the first action by the nurse?
Check to see what medication the client is taking.
Encourage the client to eat more slowly.
Assessment security.
Assess the client more thoroughly and immediately report any concerns to the provider.
The Correct Answer is D
A. While medication review may be necessary, the immediate concern is the client's current symptoms and potential need for urgent intervention.
B. Encouraging the client to eat more slowly does not address the urgent nature of the client's symptoms.
C. "Assessment security" is not a standard term or intervention. It does not provide specific guidance for addressing the client's symptoms.
D. Given the client's complaints of swelling and tightness, along with difficulty swallowing, further assessment is needed to determine the cause. This information should be reported to the provider promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Agitation can be a sign of distress, but sudden cheerfulness may be indicative of a decision to act on suicidal thoughts, as the individual may feel relieved to have made a decision.
B. Sudden cheerfulness can be a concerning sign, as it may indicate that the client has made a decision to carry out suicidal thoughts.
C. Psychomotor retardation is a symptom of depression and may not necessarily indicate imminent risk of suicide.
D. Not attending group therapy may be a sign of withdrawal or isolation, but it does not directly indicate immediate suicidal risk.
Correct Answer is D
Explanation
A. This option is too vague and doesn't provide specific guidance about the detoxification process for alprazolam.
B. Frequency of usage is one factor, but it's not the only consideration in the detoxification process.
C. A planned reduction is necessary to safely taper off alprazolam and minimize withdrawal symptoms.
D. This option provides the best guidance, emphasizing the importance of a gradual and controlled tapering process for alprazolam.
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