A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

Assess the client's bilateral hand grasp strength.

Place a padded tongue blade at the client's bedside.

Check the client's bedside glucose level.

Administer flumazenil IV per facility policy to the client.

Answer and Explanation

The Correct Answer is A

A. Assess the client's bilateral hand grasp strength: Slurred speech in a client with sickle cell crisis raises concern for stroke due to vaso-occlusion in cerebral vessels. Assessing hand grasp strength helps evaluate for unilateral weakness, a key indicator of stroke, necessitating immediate intervention.

B. Place a padded tongue blade at the client's bedside: There is no indication the client is experiencing a seizure. Seizure precautions are not a priority unless additional neurological symptoms suggest seizure activity.

C. Check the client's bedside glucose level: Hypoglycemia can cause slurred speech, but in a client with sickle cell disease, stroke is a more likely cause. Assessing neurological function should take precedence over checking glucose unless the client has a history of diabetes or other risk factors.

D. Administer flumazenil IV per facility policy to the client: Flumazenil is used to reverse benzodiazepine overdose. There is no indication that the client has received benzodiazepines or is experiencing medication toxicity.

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Correct Answer is D

Explanation

A. Apply heating blanket as needed: Fever can worsen intracranial pressure (ICP) by increasing metabolic demand. Instead, cooling measures such as antipyretics or a cooling blanket should be used to maintain normothermia and prevent further ICP elevation.

B. Position the head of bed greater than 45°: Elevating the head of the bed slightly (30–45°) promotes venous drainage and reduces ICP. However, excessive elevation (>45°) may decrease cerebral perfusion pressure (CPP), leading to inadequate brain oxygenation.

C. Administer laxatives rectally: Rectal administration can stimulate the vagus nerve and increase ICP. Oral or IV stool softeners should be preferred to prevent straining, which can further elevate ICP.

D. Decrease stimulation in environment: Reducing noise, dimming lights, and minimizing disturbances help prevent spikes in ICP by decreasing sensory overload and stress. A calm environment supports cerebral oxygenation and prevents further elevation of ICP.

A. 150 mL of greenish yellow NG drainage B. Client requests medication for nausea C. Urinary output of 250 mL over past 12 hr D. Hypoactive bowel sounds

Correct Answer is C

Explanation

A. 150 mL of greenish yellow NG drainage: This amount and color of drainage are expected after abdominal surgery, as bile-stained gastric contents can be present. It does not indicate a complication that requires provider notification.

B. Client requests medication for nausea: Nausea is a common postoperative symptom, often managed with antiemetics. While it should be addressed, it is not an urgent finding that requires immediate provider notification.

C. Urinary output of 250 mL over past 12 hr: Oliguria, defined as urine output less than 30 mL/hr (or less than 400 mL in 24 hr), suggests inadequate renal perfusion, possibly due to hypovolemia or acute kidney injury. This finding requires prompt provider notification.

D. Hypoactive bowel sounds: Reduced bowel activity is common after abdominal surgery due to anesthesia and opioid use. While monitoring is necessary, hypoactive sounds alone are not an urgent concern unless accompanied by other signs of ileus or obstruction.

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A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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