A client experiencing a sudden onset of confusion and trouble speaking at home is transported to the emergency department. The client does not understand simple commands and appears very frustrated. Which intervention should the nurse perform in the immediate management of the client?

Test for a swallowing reflex and perform communication deficit assessments.

Administer aspirin to prevent further clot formation and platelet clumping

Initiate bilateral intermittent sequential pneumatic compression devices.

Determine when symptoms began and if improved or worsened since onset.

Answer and Explanation

The Correct Answer is D

D. Assessing the time of symptom onset and determining if the symptoms have improved or worsened since onset is crucial for determining the urgency of the situation and guiding further management. This information helps the healthcare team identify the potential cause of the symptoms and decide on the appropriate course of action. Sudden onset of confusion and trouble speaking can be indicative of various serious conditions such as stroke, transient ischemic attack (TIA), intracranial hemorrhage, or other neurological emergencies.
A. Assessing for a swallowing reflex and performing communication deficit assessments are important aspects of the client's assessment but they may not be the immediate priority in the initial management of the client.
B. Administering aspirin to prevent further clot formation and platelet clumping may be appropriate if the client is suspected to have an ischemic stroke, but it should be done based on a comprehensive assessment
C. Initiating bilateral intermittent sequential pneumatic compression devices is indicated for preventing deep vein thrombosis (DVT) in hospitalized clients, but it is not the most immediate intervention for this particular client.

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Correct Answer is D

Explanation

D. Vital sign measurements, including blood pressure, heart rate, respiratory rate, and temperature, are essential for assessing the client's hemodynamic stability and overall condition. A rigid abdomen with rebound tenderness suggests a potential surgical emergency, such as bowel perforation, which could lead to sepsis and hemodynamic instability. Therefore, obtaining vital sign measurements promptly will help determine the severity of the client's condition and guide further interventions.
A. Encouraging ambulation would not be appropriate in this situation because it could exacerbate the client's discomfort and potentially worsen any abdominal pain or tenderness. Ambulation is not the priority when a client presents with signs of a possible bowel perforation.
B. Measure capillary glucose level: While monitoring blood glucose levels is important, especially in clients receiving corticosteroid treatment, it is not the priority when the client is presenting with symptoms suggestive of a serious complication such as bowel perforation. Immediate assessment and intervention to address the abdominal rigidity and rebound tenderness are needed before other assessments can be performed.
C. While bloody stools are a common symptom of IBD exacerbation, the presence of a rigid abdomen with rebound tenderness suggests a more urgent issue, such as bowel perforation, that requires immediate attention. Monitoring for bloody stools should occur concurrently with assessing and managing the client's acute abdominal symptoms.

A. Auscultate lungs for unequal breath sounds. B. Continue to monitor the drainage system. C. Lift and clear drainage from the chest tube. D. Inspect the tube insertion site for leaking.

Correct Answer is B

Explanation

B. Tidaling is an expected finding in a functioning chest drainage system and indicates proper drainage of air or fluid from the pleural space. Continuously monitoring the drainage system allows the nurse to assess the volume, color, and consistency of drainage.
A. Rising water levels during inspiration and falling during expiration are indicative of proper chest tube function, therefore, auscultation for breath sounds may not provide additional relevant information related to the functioning of the chest tube.
C. Performing this action unnecessarily may disrupt the functioning of the drainage system and should only be done if specifically instructed by the healthcare provider.
D. While it is important to monitor for leaks, the observation of tidaling in the water-seal chamber does not necessarily indicate a leak at the insertion site.

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A client experiencing a sudden onset of confusion and trouble speaking at home is transported to the emergency department. The client does not understand simple commands and appears very frustrated. Which intervention should the nurse perform in the immediate management of the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound lendemess. Which action should the nurse take?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding is most important for the nurse to monitor?

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The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?