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. Ginkgo biloba has been reported to have anticoagulant properties and may potentiate the effects of warfarin, increasing the risk of bleeding. Therefore, individuals taking warfarin should exercise caution when using ginkgo supplements and be monitored closely for signs of bleeding or changes in anticoagulant response.
B. Dandelion is not known to directly affect blood clotting or the action of warfarin.
C. Acai berry is a fruit commonly consumed for its potential antioxidant properties and health benefits. There is limited scientific evidence regarding the interaction between acai and warfarin.
D. Zinc supplementation is generally considered safe for most individuals and there is limited evidence to suggest that zinc significantly enhances the anticoagulant effects of warfarin.

A. discourage the client from discussing feelings of fear and inferiority. B. provide positive reinforcement for acting-out behavior. C. be consistent in staff limit setting. D. ignore, rather than confront, inappropriate behavior.

Correct Answer is C

Explanation

C. This approach involves establishing clear and consistent rules and boundaries, which are crucial for managing antisocial behaviors. It helps to create a structured environment where the consequences of actions are predictable and reinforces the understanding of acceptable behaviors.
A. Encouraging the client to explore and address underlying emotions, including feelings of fear and inferiority, can be an important aspect of therapy and may help mitigate manipulative behaviors over time.
B. Antisocial personality disorder is associated with behaviors that violate social norms and the rights of others. Positive reinforcement for these behaviors would not address the underlying issues and may inadvertently reinforce harmful patterns of behavior.
D. Ignoring inappropriate behavior may reinforce the notion that manipulation is an effective means of achieving desired outcomes and may lead to further boundary violations.

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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

The nurse is caring for a client who takes warfarin 10 mg PO daily and several herbal remedies. The nurse would be most concerned that the use of which herb would enhance the anticoagulant effects of warfarin?

Correct Answer is A

Explanation

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

Correct Answer is C

Explanation

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