A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?
Perform the Heimlich maneuver.
Slap the client on the back several times.
Assist the client to the floor and begin mouth-to-mouth resuscitation.
Observe the client before taking further action.
The Correct Answer is A
Choice A reason:
The Heimlich maneuver, also known as abdominal thrusts, is the recommended first aid technique for a conscious person who is choking. This maneuver helps to expel the object blocking the airway by using the air remaining in the lungs to force it out. The nurse should stand behind the person, place their arms around the person’s waist, make a fist with one hand, and place it just above the navel. The other hand should grasp the fist, and quick, upward thrusts should be performed until the object is expelled.
Choice B reason:
Slapping the client on the back several times is not the recommended first action for a conscious adult who is choking. While back blows can be effective, they are typically used in combination with abdominal thrusts and are more commonly recommended for infants. For adults, the Heimlich maneuver is preferred as the initial response.
Choice C reason:
Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate for a conscious person who is choking. Mouth-to-mouth resuscitation, or rescue breathing, is used when a person is not breathing and is unresponsive. In this scenario, the client is conscious but unable to speak, indicating a blocked airway that requires the Heimlich maneuver.
Choice D reason:
Observing the client before taking further action is not advisable in a choking emergency. Immediate intervention is crucial to prevent the situation from worsening. If the person is unable to speak, cough, or breathe, the Heimlich maneuver should be performed without delay.
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Correct Answer is B
Explanation
Choice A reason:
Removing all objects that contain latex from the client’s room is important for clients with a latex allergy, not a penicillin allergy. Latex allergies can cause severe reactions, including anaphylaxis, but this action is not relevant to a penicillin allergy.
Choice B reason:
Verifying that the client’s medication prescriptions do not include cephalosporin is crucial because cephalosporins can have cross-reactivity with penicillin. Clients with a penicillin allergy may also react to cephalosporins, so it is essential to avoid prescribing these antibiotics.
Choice C reason:
Notifying dietary services to adjust the client’s diet is not directly related to managing a penicillin allergy. Dietary adjustments are more relevant for clients with food allergies or specific dietary restrictions.
Choice D reason:
Having the client purchase a medication alert bracelet to wear in the hospital is a good practice for general safety, but it is not an immediate action the nurse should take during the admission process. The primary focus should be on ensuring that the client’s medications do not include penicillin or related antibiotics.
Correct Answer is B
Explanation
Choice A reason: Blurred vision:
While blurred vision can occur in some cases of meningitis, it is not one of the most common or definitive symptoms. Meningitis primarily affects the meninges, leading to symptoms like headache, fever, and neck stiffness. Blurred vision might be a secondary symptom due to increased intracranial pressure, but it is not as typical as other symptoms.
Choice B reason: Severe headache:
A severe headache is a hallmark symptom of meningitis. This headache is often described as intense and different from typical headaches. It is caused by the inflammation of the meninges, which are the protective membranes covering the brain and spinal cord. The headache is usually accompanied by other symptoms such as fever, neck stiffness, and sensitivity to light.
Choice C reason: Oriented to person, place, and year:
Being oriented to person, place, and year indicates normal cognitive function. However, meningitis can cause confusion, altered mental status, and even loss of consciousness in severe cases. Therefore, this finding would not be expected in a client with meningitis.
Choice D reason: Bradycardia:
Bradycardia, or a slow heart rate, is not typically associated with meningitis. Meningitis symptoms are more related to the central nervous system and include fever, headache, neck stiffness, and altered mental status. Bradycardia might occur in other conditions but is not a common finding in meningitis.