When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

Administer a prescribed antianxiolytic.

Allow the client to rest before taking the vital signs.

Notify the client representative.

Offer the client hot tea to promote relaxation.

Answer and Explanation

The Correct Answer is B

A. Administering an antianxiolytic might be premature and should only be done if prescribed and necessary.
B. Allowing the client to rest before taking vital signs helps ensure that the measurements are accurate and not influenced by recent emotional distress.
C. Notifying the client representative might be relevant later, but addressing the client's immediate needs and emotional state is the priority.
D. Offering hot tea may not be appropriate in this situation and does not directly address the need for accurate vital signs.

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Correct Answer is A

Explanation

A. Dysphagia, or difficulty swallowing, significantly increases the risk of aspiration, especially when consuming a full liquid diet that may not be easily controlled in the mouth. Aspiration can lead to serious complications, such as aspiration pneumonia.
B. Oxygen administration via a face mask does not typically increase the risk of aspiration unless the client has underlying conditions affecting swallowing.
C. Sensory aphasia affects communication but does not directly impact the swallowing mechanism, so it poses less risk of aspiration compared to dysphagia.
D. While clients with a nasogastric tube may be at some risk for aspiration, the risk is lower compared to a client with dysphagia actively consuming liquids.

A. Rubber soled slippers. B. Tennis shoes with velcro. C. Leather soled loafers. D. Slip on rubber shower shoes.

Correct Answer is B

Explanation

A. Rubber-soled slippers do not provide adequate support or stability for a client with weakness.
B. Tennis shoes with velcro offer good support, stability, and ease of use, which is important for clients with weakness or impaired mobility.
C. Leather-soled loafers may be slippery and do not provide as much support or stability.
D. Slip-on rubber shower shoes lack adequate support and can be unsafe for ambulation.

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When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is at greatest risk for aspiration?

Correct Answer is A

Explanation

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Correct Answer is B

Explanation

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