When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

Administer a prescribed antianxiolytic.

Allow the client to rest before taking the vital signs.

Notify the client representative.

Offer the client hot tea to promote relaxation.

Answer and Explanation

The Correct Answer is B

A. Administering an antianxiolytic might be premature and should only be done if prescribed and necessary.
B. Allowing the client to rest before taking vital signs helps ensure that the measurements are accurate and not influenced by recent emotional distress.
C. Notifying the client representative might be relevant later, but addressing the client's immediate needs and emotional state is the priority.
D. Offering hot tea may not be appropriate in this situation and does not directly address the need for accurate vital signs.

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Correct Answer is C

Explanation

A. Baclofen should not be stopped abruptly as it can cause withdrawal symptoms. The client should consult their healthcare provider before using other antispasmodics.
B. Monitoring intake and output every 8 hours is not specific to baclofen administration.
C. Baclofen can cause dizziness, drowsiness, and hypotension. Advising the client to move slowly and cautiously when rising and walking helps prevent falls or injury due to these side effects.
D. While muscle strength assessment is important, it is not required every 4 hours and does not specifically address the common side effects of baclofen.

A. Hypertension. B. Peripheral edema. C. Gingival hyperplasia. D. Hematuria.

Correct Answer is C

Explanation

A. Hypertension is not a common side effect of phenytoin. It is not typically associated with the medication.
B. Peripheral edema is not commonly linked to phenytoin use.
C. Gingival hyperplasia, or overgrowth of the gums, is a common side effect of phenytoin, particularly with long-term use.
D. Hematuria is not a typical side effect of phenytoin and may indicate a different medical issue.

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When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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