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 A

Explanation

A. Domestic violence is not simply about physical violence but also involves an imbalance of power where the abuser seeks to exert control over the victim through various means, including emotional, psychological, financial, and social manipulation.
B. Domestic violence can certainly lead to erratic relationships and exacerbate feelings of vulnerability but this statement does not capture the central dynamic of power and control that characterizes domestic violence.
C. Poor communication and social isolation can be contributing factors in some cases of domestic violence but they are not necessarily central to the dynamic.
D. This statement partially captures the psychological impact of domestic violence on victims, including emotional injury and learned helplessness. However, it does not explicitly address the underlying dynamic of power and control.

A. The CAGE Questionnaire B. The Clinical Institute Withdrawal Assessment Scale C. The Abnormal Involuntary Movement Scale D. Opioid Risk Tool – OUD

Correct Answer is A

Explanation

A. he CAGE questionnaire is a widely used screening tool for alcohol use disorder (AUD). It consists of four questions that assess the client's alcohol consumption, attempts to cut down or control drinking, feelings of guilt about drinking, and whether alcohol use interferes with daily activities or responsibilities.
B. The CIWA is a tool used to assess the severity of alcohol withdrawal symptoms in individuals with alcohol dependence who are undergoing detoxification or withdrawal management. The CIWA is not specifically used for screening alcohol use disorder but rather for monitoring and managing alcohol withdrawal symptoms in individuals with known alcohol dependence.
C. The AIMS is a tool used to assess for the presence and severity of abnormal involuntary movements, particularly those associated with antipsychotic medications or conditions such as tardive dyskinesia. It is not used for screening alcohol use disorder.

D. The ORT-OUD is a screening tool specifically designed to assess the risk of opioid use disorder (OUD) in individuals who are prescribed opioid medications for chronic pain. It is not used for screening alcohol use disorder.

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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:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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