The nurse observes a client drooling during mealtime. The client complains that his tongue feels swollen, and his jaw feels tight. What is the first action by the nurse?
Check to see what medication the client is taking.
Encourage the client to eat more slowly.
Assessment security.
Assess the client more thoroughly and immediately report any concerns to the provider.
The Correct Answer is D
A. While medication review may be necessary, the immediate concern is the client's current symptoms and potential need for urgent intervention.
B. Encouraging the client to eat more slowly does not address the urgent nature of the client's symptoms.
C. "Assessment security" is not a standard term or intervention. It does not provide specific guidance for addressing the client's symptoms.
D. Given the client's complaints of swelling and tightness, along with difficulty swallowing, further assessment is needed to determine the cause. This information should be reported to the provider promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Brain atrophy is a common physiological change in the brain of individuals with Alzheimer's disease.
B. An overabundance of plaques, specifically amyloid beta, is a characteristic feature of Alzheimer's disease.
C. An overabundance of tangles, specifically tau protein, is also a characteristic feature of Alzheimer's disease.
D. Enlargement of the hippocampus is not typically associated with Alzheimer's disease; rather, it tends to shrink.
E. Enlarged cerebral cortex is not a typical physiological change in Alzheimer's disease; it actually tends to shrink.
Correct Answer is A
Explanation
A. Delirium is characterized by a fluctuating level of consciousness, which can include periods of hypervigilance.
B. A slow onset of confusion and agitation is more characteristic of dementia rather than delirium.
C. A decrease in output and vital signs may indicate a different condition, but it is not specific to delirium.
D. Delirium is characterized by an acute onset and is typically short-lived, usually lasting days to weeks. Symptoms lasting longer than a month would suggest a different diagnosis.
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