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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Incorrect. While maintaining proper nutrition is important, this statement is not directly related to the use of risperidone.

B) Correct. Risperidone, an atypical antipsychotic, can be associated with metabolic side effects, including hypertension. Therefore, monitoring blood pressure is important.

C) Incorrect. While regular monitoring of blood parameters may be necessary for some medications, it is not a specific requirement for risperidone.

D) Incorrect. While weight changes can occur with risperidone, there is no specific indication to increase caloric intake in this context.

A. "He may begin to try to cover recognition of his memory loss by creating events." B. "He may have difficulty in a motor skill such as walking." C. "The inability to communicate with speech comes immediately after the early signs." D. "He may not recognize you and other people who have been in his life."

Correct Answer is A

Explanation

A. "He may begin to try to cover recognition of his memory loss by creating events." As
dementia progresses, individuals may experience confabulation, which involves creating false memories to compensate for memory loss. This is a common symptom seen in the middle stages of dementia.

B. "He may have difficulty in a motor skill such as walking." While motor skills may be affected in the later stages of dementia, it is not typically one of the early signs.

C. "The inability to communicate with speech comes immediately after the early signs." This statement is not accurate. Communication difficulties may occur in later stages, but it is not an immediate progression from early signs.

D. "He may not recognize you and other people who have been in his life." This symptom, known as agnosia, may occur in later stages of dementia, but it is not one of the early signs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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