A nurse is caring for a client.

Exhibits

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Assist the client to the bathroom.

Initiate seizure precautions.

Record GCS every 15 min for the first 4 hr.

Elevate the head of the bed

Keep the client's head in midline position

Encourage the client to cough

Decrease oxygen to 1.5L/min via nasal cannula

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}

Rationale
• Assist the client to the bathroom.
•   Non-essential: The client’s current condition indicates severe changes, including a significant drop in consciousness and worsening vital signs. Immediate priorities involve stabilization and monitoring rather than assisting with bathroom needs.
• Initiate seizure precautions.
•   Anticipated: The client’s deteriorating condition, including restlessness, agitation, and decreased level of consciousness, increases the risk of seizures. Initiating seizure precautions is appropriate to ensure safety.
• Record GCS every 15 min for the first 4 hr.
•   Anticipated: The Glasgow Coma Scale (GCS) score of 9 indicates a significant decrease in consciousness. Frequent monitoring of GCS is crucial to assess changes in neurological status and to guide further intervention.
• Elevate the head of the bed.
•   Anticipated: Elevating the head of the bed can help with cerebral perfusion and decrease intracranial pressure. This is a common intervention for clients with neurological issues to improve comfort and safety.
• Keep the client's head in midline position.
•   Anticipated: Maintaining a midline position helps ensure optimal cerebral perfusion and reduces the risk of complications. It is particularly important in clients with neurological changes.
• Encourage the client to cough.
•   Non-essential: Given the client's current level of consciousness and agitation, encouraging coughing might not be appropriate and could cause further distress or complications.
• Decrease oxygen to 1.5L/min via nasal cannula.
•   Contraindicated: The client’s oxygen saturation has dropped to 90% despite receiving 6 L/min of oxygen. Decreasing the oxygen flow could further impair oxygenation. The priority is to maintain or increase oxygen levels to ensure adequate oxygenation.

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Correct Answer is B

Explanation

A. Speech therapist: A speech therapist is typically involved in addressing communication and swallowing difficulties, not difficulties with using utensils.
B. Occupational therapist: This is correct as an occupational therapist specializes in helping clients with daily living activities, including fine motor skills and adaptive techniques for using utensils.
C. Physical therapist: Physical therapists focus on improving mobility, strength, and coordination but do not primarily address difficulties with using utensils.
D. Recreational therapist: Recreational therapists focus on leisure activities and hobbies, which are not directly related to the use of utensils for eating.

A. Provide a diet that is low in protein. B. Avoid administration of the influenza vaccine. C. Maintain the client on bed rest. D. Decrease fluid intake to 1,500 mL daily.

Correct Answer is C

Explanation

A. Provide a diet that is low in protein: This is incorrect because clients in sickle cell crisis require a well-balanced diet with adequate protein, along with increased fluid intake to help maintain hydration and reduce the risk of further complications.
B. Avoid administration of the influenza vaccine: This is incorrect because vaccination, including the influenza vaccine, is important for preventing infections that can exacerbate sickle cell crises.
C. Maintain the client on bed rest: This is correct because bed rest helps to reduce the energy expenditure and stress on the body, which can help manage pain and prevent further complications during a sickle cell crisis.
D. Decrease fluid intake to 1,500 mL daily: This is incorrect because increased fluid intake is crucial in sickle cell crisis to help prevent dehydration and promote proper blood flow, thereby reducing the risk of vaso-occlusive episodes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Parkinson's disease. The client displays difficulty using utensils while eating at mealtime. For which of the following interdisciplinary team members should the nurse recommend a referral?

Correct Answer is B

Explanation

A nurse is assisting with the plan of care for a client who is experiencing sickle cell crisis. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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