The practical nurse (PN) is providing care for a client with a history of a stroke and who has aphasia. The client is exhibiting restlessness, shallow respirations and is clenching teeth. Which problem should the PN assess further?
Alteration in comfort.
Deficit in diversional activity.
Elevated blood pressure.
Change in blood glucose level.
The Correct Answer is A
A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Offer fluids: Offering fluids is not appropriate when the client shows signs of central cyanosis, as it does not address impaired oxygenation and may pose an aspiration risk if the client is hypoxic or has altered mental status.
B. Administer oxygen: Cyanosis of the lips and tongue indicates poor oxygen saturation and tissue hypoxia. Administering oxygen is the priority action to improve oxygen delivery and prevent respiratory compromise.
C. Ask about pain: While assessing pain is important, it is not the priority in the presence of cyanosis, which reflects a potentially life-threatening oxygenation issue requiring immediate intervention.
D. Provide mouth care: Mouth care is not urgent and does not address the underlying problem of hypoxia. It should be deferred until after the client’s oxygenation status is stabilized.
Correct Answer is ["31"]
Explanation
Total volume to be infused: 250 mL of tube feeding.
To be infused over 8 hours.
Calculate the infusion rate in mL per hour.
Infusion rate (mL/hour) = Total volume (mL) / Total infusion time (hours)
= 250 mL / 8 hours
= 31.25
Round to the nearest whole number: 31.
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