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 D

Explanation

A. Neologisms refer to made-up words or phrases that have meaning only to the individual. The client's response does not include invented terms but rather consists of real words that are nonsensically grouped.

B. Echolalia is the repetition of words or phrases spoken by others. The client's response does not reflect repetition of the nurse's words but rather a disjointed response of their own.

C. Pressured speech involves rapid and often incoherent speech that reflects a sense of urgency. The client's response lacks the rapid flow characteristic of pressured speech.

D. Clang association is characterized by speech in which the individual connects words based on their sound rather than their meaning. The client's response ("medications, abbreviations, deviations, mediations") demonstrates this pattern, as the words are linked by similar sounds rather than by content or coherent thought.

A. "It sounds as though the antidepressants are working well. Just ask the client if the client is experiencing any side effects and let me know." B. "I'm concerned. Sometimes depressed people seem contented when they have decided to commit suicide. Let's schedule an appointment for tomorrow." C. "Since the client is eating, sleeping, and not behaving inappropriately, there's nothing to worry about. Just let me know if the client starts getting irritable or has trouble sleeping." D. "The client sounds hypomanic. Let's schedule an appointment for this week for an evaluation. The client may need additional or different medication."

Correct Answer is D

Explanation

A. "It sounds as though the antidepressants are working well. Just ask the client if the client is experiencing any side effects and let me know." This response does not adequately address the change in mood and the potential for hypomania. It assumes the change is solely due to the antidepressants.

B. "I'm concerned. Sometimes depressed people seem contented when they have decided to commit suicide. Let's schedule an appointment for tomorrow." While it's important to assess for suicidality, the description provided does not indicate immediate suicidal intent. The client's behavior is more indicative of hypomania.

C. "Since the client is eating, sleeping, and not behaving inappropriately, there's nothing to worry about. Just let me know if the client starts getting irritable or has trouble sleeping." This response downplays the significance of the mood change and does not address the potential for hypomania.

D. "The client sounds hypomanic. Let's schedule an appointment for this week for an evaluation. The client may need additional or different medication." This response correctly identifies the potential for hypomania and takes appropriate action by scheduling an evaluation. Adjusting the client's medication may be necessary to address the change in mood.

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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

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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