The nurse is caring for a client after an endoscopy. The client is lethargic and not responding to verbal commands. The priority nursing action is to:

assess the client's airway and breathing.

assess the client's gag reflex.

call the physician immediately.

document this as normal findings and reassess in half an hour.

Answer and Explanation

The Correct Answer is A

A. The client's lethargy and lack of response to verbal commands raise concerns about their level of consciousness and potential airway compromise. Assessing the client's airway and breathing involves ensuring that the airway is clear, assessing respiratory rate and effort, and monitoring oxygenation.
B. Assessing the gag reflex can provide additional information about airway protection. However, it should not delay assessment and intervention for airway and breathing concerns.
C. Contacting the physician may be necessary but it is not the priority nursing action in this situation. The nurse should first assess the client's airway and breathing to ensure their safety and stability.
D. The client's lethargy and unresponsiveness are not normal findings after an endoscopy and require immediate assessment and intervention. Delaying assessment and intervention could lead to serious complications, including respiratory compromise or airway obstruction.

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Correct Answer is B

Explanation

B. It acknowledges that recovery is not a quick fix or a one-time event but rather a lifelong journey that involves ongoing effort, self-awareness, and personal growth. Recognizing that recovery occurs in steps suggests an understanding of the incremental progress and challenges that may be encountered along the way.
A. This statement demonstrates some understanding of the concept of recovery from alcohol abuse, but it may not fully reflect the comprehensive nature of recovery.
C. Al-Anon is a mutual support program for people affected by someone else's alcoholism, typically family members and friends. This does not directly involve the client.
D. Detoxification, or the process of clearing alcohol and its byproducts from the body, is an important initial step in recovery, but it is not synonymous with recovery itself.

A. Isolate the client from all stressful situations that may precipitate a suicide attempt. B. Have a one-to-one sitter for outpatient use. C. Identify community resources for the client to use in a crisis. D. Educate the family about providing a safe and structured environment for the client. E. Assist the client to develop more effective coping mechanisms.

Correct Answer is ["C","D","E"]

Explanation

C. Identifying community resources is essential as it provides the client with accessible support during crises.
D. Educating the family about creating a safe and structured environment is also important because it involves the client's support system in their care, which can help prevent future crises.
E. Assisting the client in developing more effective coping mechanisms is vital for long-term management and recovery, as it empowers the client to handle stressors more healthily.
A. Isolating the client from all stressful situations is not practical or beneficial as it does not teach coping mechanisms or resilience.
B. Having a one-to-one sitter might be necessary in some inpatient settings but is not feasible or indicated for outpatient care.

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The nurse is caring for a client after an endoscopy. The client is lethargic and not responding to verbal commands. The priority nursing action is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating clients about recovery from alcohol abuse. Which statement indicates that learning has occurred?

Correct Answer is B

Explanation

A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

The nurse in the Emergency Department (ED) assesses a 17-year-old client exhibiting symptoms of opiate intoxication. Which of the following should be the nurse's priority action?

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