A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the client on use of call light.

Apply an ambulation alarm to the client’s leg.

Apply restraints to the client PRN.

Raise the four side rails of the client’s bed.

Check on the client hourly

Answer and Explanation

Correct Answer : A,B,D,E

A.   Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B.   Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.

C.   Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D.   Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.

E. Checking on the client hourly is an essential intervention to monitor the client’s mental status and ensure safety. Frequent assessments allow for early identification of complications related to opioid use, such as respiratory depression or increased sedation.

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Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Drawing legs up into a fetal position may indicate discomfort or agitation.
B. Facial muscle relaxation is indicative of a therapeutic response to the massage.
C. An increased respiratory rate may suggest distress or discomfort.
D. Drooping shoulders suggest relaxation and a positive response to the massage.
E. Maintaining an expected pulse rate indicates that the massage is not causing undue stress or discomfort.

A. Butterfly rash on the face B. Ulnar deviation C. Heberden’s nodes D. Bouchard’s nodes

Correct Answer is B

Explanation

A. A butterfly rash on the face is associated with systemic lupus erythematosus (SLE), not rheumatoid arthritis.
B. Ulnar deviation of the joints is a characteristic finding in rheumatoid arthritis, caused by inflammation and destruction of the joint structures.
C. Heberden’s nodes are associated with osteoarthritis, not rheumatoid arthritis.
D. Bouchard’s nodes are also associated with osteoarthritis, not rheumatoid arthritis.

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A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is B

Explanation

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