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 A
Explanation
A. This outcome is specific, measurable, and timebound. It addresses the client's impaired social interactions and sets a realistic expectation for improvement within a short timeframe.
B. While this outcome is specific, it may not be achievable within a short timeframe and may not directly address the issue of egocentrism.
C. This outcome focuses on verbalization but may not necessarily lead to actual interaction or address the issue of egocentrism.
D. While this outcome is relevant, it is not as specific or timebound as option A.
Correct Answer is B
Explanation
A) Incorrect. While aging can contribute to cognitive changes, it is not the primary factor in the acute onset of delirium.
B) Correct. This statement highlights the acute and rapid onset of behavioral changes, which is characteristic of delirium. Delirium is an acute confessional state characterized by alterations in cognition, attention, and level of consciousness. It often has a sudden onset.
C) Incorrect. Chronic forgetfulness may be indicative of dementia or other cognitive disorders, but it does not support the acute onset seen in delirium.
D) Incorrect. Independence and living alone do not directly relate to the acute onset of delirium.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.