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 ["10"]
Explanation
Dose (mL) = Desired dose (mg) / Available dose (mg/mL) Plugging in the values from the question, we get:
Dose (mL) = 80 mg / (40 mg / 5 mL) Simplifying the fraction, we get:
Dose (mL) = 80 mg / 8 mg/mL Dividing both sides by 8, we get:
Dose (mL) = 10 mL
Therefore, the nurse should administer 10 mL of fluoxetine per dose.
Correct Answer is B
Explanation
A) Incorrect. While kidney function is important for overall health, it is not the primary focus for ruling out medical conditions contributing to major depressive disorder.
B) Correct. Thyroid function can significantly impact mood and energy levels. Abnormalities in thyroid function can sometimes present with symptoms similar to depression, so a thyroid panel (including TSH, T3, and T4 levels) is an important test to consider.
C) Incorrect. While liver function is important for overall health, it is not the primary focus for ruling out medical conditions contributing to major depressive disorder.
D) Incorrect. A urinalysis with culture is not a standard test for ruling out medical conditions contributing to major depressive disorder. It is more relevant for assessing urinary tract infections or kidney function.
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