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 B
Explanation
A. Administer thiamine intramuscular (IM) Administering thiamine is important, especially in
clients with alcohol abuse, to prevent or treat potential Wernicke Korsakoff syndrome. However, the primary intervention when admitting a client is addressing immediate physical and psychological needs, such as personal hygiene.
B. Assist the client with personal hygiene needs This is the primary intervention upon admission.
It addresses the client's immediate physical and psychological wellbeing and helps establish a therapeutic rapport.
C. Place the client on continuous observation While observation may be necessary for safety, it is not the primary intervention in this scenario. Addressing personal hygiene needs takes precedence.
D. Explain milieu therapy Milieu therapy is an important aspect of a comprehensive treatment plan, but it is not the primary intervention upon admission. Immediate physical care and safety are the initial priorities.
Correct Answer is A
Explanation
A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This
intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.
B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.
C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.
D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.
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