Author Question: A client in the clinic complaining of abdominal pain tells the nurse that the food eaten last night ... (Read 77 times)

segrsyd · **on:** Jul 22, 2018

A client in the clinic complaining of abdominal pain tells the nurse that the food eaten last night must have been tainted. What action would the nurse take after the client states that the food was tainted?

1. Advise the client to take an antacid.
2. Ask open-ended questions to further assess.
3. Call an ambulance before assessing further.
4. Tell the client the physician does not need to assess the client.

Question 2

The client has been receiving chlorpromazine (Thorazine) for the treatment of schizophrenia. The nurse assesses that the client has tardive dyskinesia. What describes the result of the nurse's assessment?

1. Severe muscle spasms of the back, neck, and tongue
2. An inability to rest or relax and restlessness
3. Unusual facial movements and lip smacking
4. Tremor, muscle rigidity, and a shuffling gait

Jsherida · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2. Ask open-ended questions to further assess.

Rationale:
The nurse must recognize that the client has not given the nurse enough information. The client could, indeed, have eaten bad food or may be experiencing appendicitis. The nurse asks more questions followed by a physical examination. Short-cut decisions here could be harmful for this client. The nurse would not give advice about taking a medication. The nurse does not have enough information to make the decision to call an ambulance. Since the nurse does not have enough information, telling the client that a physician does not need to assess the client is inappropriate.

Answer to Question 2

3. Unusual facial movements and lip smacking

Rationale:
Tardive dyskinesia is characterized by unusual tongue and face movements such as lip smacking and wormlike motions of the tongue. Severe muscle spasms of the back, neck, and tongue are known as acute dystonia, not tardive dyskinesia. An inability to rest or relax and restlessness are known as akathisia, not tardive dyskinesia. Tremor, muscle rigidity, and a shuffling gait are known as Parkinsonism, not tardive dyskinesia.