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 C
Explanation
Choice A reason: Pruritus:
Pruritus, or itching, can be uncomfortable and may indicate underlying conditions such as dry skin, allergies, or liver disease. However, it is not typically an immediate threat to health and can often be managed with topical treatments or antihistamines.
Choice B reason: Swollen gums:
Swollen gums can be a sign of gingivitis or other dental issues. While important to address, it is not usually an urgent condition unless it is causing severe pain or infection. Dental problems can lead to complications if untreated, but they are generally not life-threatening.
Choice C reason: Dysphagia:
Dysphagia, or difficulty swallowing, is a serious condition that can lead to aspiration, malnutrition, and dehydration. It can be caused by neurological disorders, structural abnormalities, or other medical conditions. Because it can directly impact the client’s ability to eat and drink safely, it is a priority for immediate assessment and intervention.
Choice D reason: Urinary hesitancy:
Urinary hesitancy, or difficulty starting urination, can be a symptom of benign prostatic hyperplasia (BPH) or other urinary tract issues. While it can cause discomfort and lead to urinary retention, it is generally not as immediately life-threatening as dysphagia.
Correct Answer is B
Explanation
Choice A reason:
While articulating expectations is important, the nurse’s response is more focused on addressing the client’s feelings and encouraging participation in therapy. Simply stating expectations without addressing the client’s emotions may not be as effective.
Choice B reason:
The nurse’s response demonstrates empathy by acknowledging the client’s feelings and gently guiding them towards participating in group therapy. This approach helps build trust and rapport, which are essential in therapeutic relationships, especially with clients exhibiting delusional behavior.
Choice C reason:
Setting limits on manipulative behavior is important, but in this context, the nurse’s response is more about encouraging participation and showing understanding rather than strictly setting limits.
Choice D reason:
Reflection involves mirroring the client’s feelings or statements to show understanding. While the nurse’s response does show understanding, it is not a direct example of reflection. The primary focus is on empathy and encouragement.