An older male client is admitted with the medical diagnosis of a possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side.
When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water.
Which action should the nurse take?
Ask the wife to stop and assess the client's swallowing reflex.
Give the wife a straw to help facilitate the client's drinking.
Assist the wife and carefully give the client small sips of water.
Obtain thickening powder before providing any more fluids.
The Correct Answer is A
Choice A rationale:
Ask the wife to stop and assess the client's swallowing reflex. Rationale: While assessing the client's swallowing reflex is important, the immediate priority is to provide hydration and comfort to the client, especially if the client is tearful and attempting to drink water. The nurse should assist the wife in providing small sips of water while being cautious and observing the client's ability to swallow safely.
Choice B rationale:
Give the wife a straw to help facilitate the client's drinking. Rationale: Giving the wife a straw may be helpful, but it does not address the client's immediate need for hydration and assistance with drinking. The nurse should actively assist in providing water to the client while assessing the client's ability to swallow safely.
Choice C rationale:
Assist the wife and carefully give the client small sips of water. Rationale: This is the correct answer. The nurse's immediate priority should be to assist the client with hydration. Providing small sips of water while being cautious and observing the client's ability to swallow safely is an appropriate action. This can help address the client's immediate needs for comfort and hydration.
Choice D rationale:
Obtain thickening powder before providing any more fluids. Rationale: While thickening powder may be necessary for clients with swallowing difficulties, it may cause unnecessary delay in providing hydration to the client in distress. The nurse should first provide water and assess the client's swallowing abilities. If thickened liquids are indicated, they can be administered later as per the healthcare provider's orders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Objective data. Rationale: Objective data are observable and measurable facts obtained through physical examination or diagnostic tests. The statement incorrectly labels the data as objective when it is, in fact, based on the client's feelings and perceptions, making it subjective.
Choice B rationale:
Subjective data. Rationale: Subjective data are information provided by the client, including their feelings, perceptions, and experiences. The statement correctly labels the data as subjective, as it reflects the client's report of thirst and hunger.
Choice C rationale:
Primary data. Rationale: Primary data are original data collected directly from the source, such as a client's medical history or interview. However, this classification does not address the nature of the data as being subjective or objective, so the statement does not provide a complete answer.
Choice D rationale:
Secondary data. Rationale: Secondary data are data obtained from sources other than the client, such as medical records or research studies. Similar to choice C, this classification does not address the nature of the data as being subjective or objective.
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. Antihypertensive drugs typically work by reducing blood pressure through various mechanisms, such as dilating blood vessels, reducing blood volume, or affecting the heart's workload. They do not increase blood flow to the heart and kidneys.
Choice B rationale:
This is the correct answer. Antihypertensive drugs work by affecting different aspects of the cardiovascular system, such as reducing blood vessel constriction (vasodilation), decreasing blood volume, or slowing the heart rate. By affecting these components, they can lower blood pressure.
Choice C rationale:
This statement is incorrect. Antihypertensive drugs can interact with other medications or supplements, potentially causing adverse effects or drug interactions. It's essential for the client to inform their healthcare provider of all medications and supplements they are taking to ensure safe and effective treatment.
Choice D rationale:
This statement is incorrect. Antihypertensive drugs do not cure hypertension but help control it. Clients need to understand that they will likely need to take these medications long-term to manage their blood pressure effectively.
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