A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Monitor the client's electrolyte levels.
Perform passive range of motion on each extremity.
Suction saliva from the client's mouth.
Record the client's intake and output.
The Correct Answer is C
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.
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Correct Answer is B
Explanation
A. Using a thermometer to check the temperature of bath water is a safe practice that helps prevent burns, which is important for clients with PVD who may have reduced sensation.
B. Wearing stockings with elastic tops can restrict blood flow and is generally not recommended for clients with PVD; clients should use non-restrictive stockings instead.
C. Not going barefoot is a good practice to prevent injuries and ulcers, which are risks for clients with PVD.
D. Avoiding crossing the legs is advisable as it helps maintain adequate blood flow and reduces the risk of circulation problems.
Correct Answer is C
Explanation
A. Benztropine is an anticholinergic agent, which reduces salivation rather than causing excessive salivation.
B. Diarrhea is not a typical side effect of benztropine; constipation is more likely due to its anticholinergic properties.
C. Difficulty voiding is an anticholinergic adverse effect of benztropine, as it can cause urinary retention. The client should report this symptom immediately to prevent complications.
D. Slow pulse is not a common adverse effect of benztropine; it may actually increase heart rate due to its anticholinergic effects.