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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.6"]
Explanation
To determine how many milliliters (mL) of diazepam the nurse should administer to the client, first, we need to calculate the amount of medication needed for each dose.
The prescribed dose is 8 mg of diazepam.
Volume= Desired dose/available concentration per ml
Available concentration per ml= 10mg/2ml Available concentration per ml= 5mg/ml Volume= 8mg/5mg per ml
Volume= 1.6ml
So, the nurse should administer 1.6 mL of diazepam to the client.
Correct Answer is ["A","C","G"]
Explanation
A. Regular physical activity is a cornerstone of prediabetes management. Exercise helps improve insulin sensitivity, promotes weight loss, and reduces the risk of progression to type 2 diabetes.
C. Weight reduction is an essential component of prediabetes management, especially for individuals who are overweight or obese. Losing as little as 5-10% of body weight can significantly improve insulin sensitivity and reduce the risk of developing type 2 diabetes.
G. Nutrition education: Nutrition education is a crucial component of prediabetes management. Providing education on healthy eating habits, portion control, carbohydrate counting, and making nutritious food choices can empower individuals with prediabetes to make positive dietary changes that support blood sugar control and overall health.
B. Short-acting insulin is not typically used in the treatment of prediabetes. Insulin therapy is usually reserved for individuals with type 1 diabetes or advanced type 2 diabetes who cannot adequately control blood sugar levels with oral medications or lifestyle interventions.
D. While oral antidiabetic medications may be prescribed for individuals with type 2 diabetes, they are not typically used as first-line therapy for prediabetes. Lifestyle modifications, such as diet and exercise, are usually the primary approach for managing prediabetes.
E. Individuals with prediabetes should generally aim to moderate their carbohydrate intake, particularly refined carbohydrates and added sugars, to help improve blood sugar control and reduce the risk of developing type 2 diabetes.
F. Similar to short-acting insulin, long-acting insulin is not typically used in the treatment of prediabetes. Insulin therapy is generally reserved for individuals with type 1 diabetes or advanced type 2 diabetes who require insulin to control blood sugar levels.
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