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. This is often a red flag that the client may not be free to act or speak on their own behalf, which is a common situation among victims of human trafficking.
A. A non-working cell phone alone may not be sufficient evidence to conclusively suspect human trafficking, as there could be various reasons for a phone not working.
C. Human traffickers often exploit victims by transporting them across state or international borders under false pretenses, such as offering a vacation or job opportunity. However, it's crucial to gather more information and assess the client's situation further before jumping to conclusions.
D. Language diversity is common in healthcare settings and may not always be indicative of trafficking.

A. "It's just a matter of time and I will be well." B. "I can fight this and lick it." C. "I deserve to be this way." D. "If I ignore this, it will go away."

Correct Answer is C

Explanation

C. This attitude suggests a sense of self-blame or low self-worth commonly seen in individuals with depression. They may feel undeserving of happiness or believe that their suffering is justified. This attitude can hinder the individual's willingness to seek help or engage in treatment, as they may believe that they do not deserve support or that their situation is hopeless.
A. This attitude may reflect optimism or hopefulness which is not a common finding in individuals with depression. Hopelessness is more common in depression.
B. This attitude reflects a sense of determination and agency in overcoming the illness. This is not a typical finding in depression.
D. Some individuals with depression may attempt to cope by minimizing or ignoring their symptoms, hoping that they will resolve on their own. However, untreated depression typically does not improve without intervention and may worsen over time.

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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

A nurse is providing care for a client who is malnourished and appears exhausted. What data would cause the nurse to suspect the client is a victim of human trafficking? The client :

Correct Answer is B

Explanation

During assessment, the nurse is most likely to find the attitude of the depressed client toward his illness to be:

Correct Answer is C

Explanation

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