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 C

Explanation

A. A depressant Depressants typically slow down the central nervous system, leading to
symptoms like sedation, slowed heart rate, and reduced blood pressure. The symptoms described in the question, such as tachycardia, hypertension, restlessness, and agitation, are not
characteristic of depressant use.

B. An opioid Opioids primarily lead to central nervous system depression, resulting in symptoms like respiratory depression, sedation, and decreased heart rate. The symptoms described in the question, such as tachycardia and restlessness, are not typical of opioid use.

C. A stimulant Stimulants, such as amphetamines or cocaine, lead to increased activity in the central nervous system, resulting in symptoms like tachycardia, hypertension, restlessness, and agitation. These symptoms align with the presentation described in the question.

D. An inhalant Inhalants can lead to a variety of effects, including dizziness, confusion, and sometimes increased heart rate. However, they are not typically associated with the specific symptoms of tachycardia, hypertension, restlessness, and agitation described in the question.

A. Encourage descriptions of perceived failures B. Set limits on manipulative behaviors C. Provide activities that can be accomplished D. Teach aggressive communication skills

Correct Answer is C

Explanation

A. Encouraging descriptions of perceived failures may further exacerbate the client's poor self- esteem and is not a therapeutic intervention.
B. While setting limits is important in managing behavior, it may not directly address the underlying issue of poor self-esteem.
C. Providing activities that can be accomplished can help boost the client's confidence and self- esteem.
D. Teaching aggressive communication skills is not appropriate and may contribute to further negative self-perception.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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