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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Correct Answer is C

Explanation

A. Inflammation of the tongue is associated with vitamin B deficiencies, not vitamin C.
B. Pale, brittle nails are more indicative of iron deficiency rather than vitamin C deficiency.
C. Dry, red conjunctiva is a manifestation of scurvy, a condition caused by vitamin C deficiency.
D. Impaired wound healing is a general sign of malnutrition but is not specific to vitamin C deficiency.

A. Distraction B. Biofeedback C. Guided imagery D. Meditation

Correct Answer is A

Explanation

A. This statement reflects a sense of blame and responsibility but may not necessarily indicate a body image disturbance.A. Listening to music is a form of distraction, diverting the client's attention away from pain.
B. Biofeedback involves using electronic monitoring to help individuals gain conscious control over physiological processes, not applicable in this context.
C. Guided imagery involves using the imagination to create calming mental images, not directly related to listening to music.
D. Meditation involves a state of focused attention and may not be as directly applicable during a medical procedure.
B. This statement may indicate frustration with physical therapy progress but does not directly address body image.
C. This statement reflects guilt or self-blame but may not necessarily indicate a body image disturbance.
D. This statement directly addresses the client's perception of their body image following the amputation.

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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 is collecting data from a client who is receiving chemotherapy and is showing manifestations of malnutrition. Which of the following indicates a Vitamin C deficiency?

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Correct Answer is A

Explanation

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