Question

A nurse on a mental health unit is assisting in the care of a client who has a history of violent behavior. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Provide opportunities for physical exercise.

Rationale :

✍️ Physical exercise provides a safe and effective outlet for tension, frustration, and excess energy that may contribute to aggressive behavior.

✍️ Regular exercise can help decrease anxiety, improve mood, and reduce the likelihood of violent outbursts.

✍️ The nurse should encourage activities appropriate to the client's physical ability, such as walking, using exercise equipment, or participating in recreational activities.

✍️ Offering structured physical activity is a nonpharmacological intervention that promotes self-control and emotional regulation.

✍️ The nurse should also observe for early signs of escalating agitation and intervene before aggressive behavior occurs.

✍️ Maintaining a calm, nonthreatening approach and setting clear behavioral limits further helps prevent violence.

✍️ Providing opportunities for exercise supports a therapeutic environment while reducing the risk of injury to the client and others.

✍️ Physical exercise is an appropriate nursing intervention to help manage a client with a history of violent behavior.

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Answer 2

Correct Answers

Blank 1 Correct Option: pressure injury
Blank 2 Correct Option: urinary incontinence

Rationale :

Pressure injury

♦️ The client has paraplegia and cannot move or feel sensation below the T10 level, creating prolonged pressure over bony prominences.

♦️ Loss of sensation prevents the client from recognizing discomfort that would normally prompt a position change.

♦️ The client depends on caregivers and a hydraulic lift for transfers, confirming significant limitations in independent mobility.

♦️ A Braden Scale score of 15 indicates an increased risk for developing a pressure injury.

♦️ The client’s skin is sometimes described as moist and warm, which makes it more vulnerable to friction, shear, and maceration.

♦️ Repositioning every 2 hours is an appropriate preventive measure, but it does not completely eliminate the risk.

♦️ Adequate nutritional intake supports tissue repair and skin integrity, although immobility and moisture remain significant threats.

♦️ The assessment findings therefore identify pressure injury as the complication for which this client is most at risk.

Urinary incontinence

♦️ Urinary incontinence repeatedly exposes the skin to moisture and irritating substances contained in urine.

♦️ Prolonged moisture softens the outer skin layer and causes maceration, making the skin easier to damage.

♦️ Moisture also increases friction when the client is repositioned or transferred.

♦️ The client cannot independently move away from wet bedding because of paraplegia.

♦️ Reduced sensation may prevent the client from recognizing that the skin or linens are wet.

♦️ The nurse should provide prompt incontinence care, apply a moisture barrier, and keep the skin clean and dry.

♦️ Frequent skin assessment is especially important around the sacrum, buttocks, hips, and heels.

♦️ Urinary incontinence is the listed factor that most directly contributes to the client’s risk for pressure injury.

❌ Dehydration

♦️ The client’s urine specific gravity is 1.012 in week 1 and 1.008 in week 2, both within the expected range of 1.005–1.030.

♦️ The findings do not show concentrated urine or other evidence suggesting inadequate hydration.

♦️ Dehydration is therefore not the complication most strongly supported by the assessment data.

❌ Urinary tract infection

♦️ Urinary incontinence can increase the risk of a urinary tract infection, but no current findings indicate infection.

♦️ The client has normal post-void residual volumes and no reported fever, dysuria, cloudy urine, or abnormal urine concentration.

♦️ The scenario more directly supports a pressure injury risk from immobility and moisture.

❌ Urine specific gravity

♦️ The urine specific gravity values are within the stated normal range and do not indicate dehydration or impaired urine concentration.

♦️ A normal urine specific gravity does not directly cause pressure-related skin breakdown.

♦️ Urinary incontinence, rather than urine specific gravity, exposes the skin to damaging moisture.

❌ Post-void residual urine

♦️ The post-void residual volumes of 90 mL and 80 mL are below 100 mL and are identified as normal in the scenario.

♦️ These values do not indicate significant urinary retention or incomplete bladder emptying.

♦️ A normal residual volume does not explain the client’s pressure injury risk as directly as urinary incontinence.

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Answer 3

Correct Answers:

"I should use a firm mattress in my baby's crib."

Rationale :

🌹 A firm mattress provides a safe, flat sleeping surface and significantly reduces the risk of suffocation and Sudden Infant Death Syndrome (SIDS).

🌹 Infants should always sleep on a firm, well-fitting mattress covered by a fitted sheet with no gaps between the mattress and crib sides.

🌹 The crib should be free of pillows, blankets, bumper pads, stuffed animals, and other soft objects that could obstruct the infant's airway.

🌹 The American Academy of Pediatrics (AAP) recommends placing infants on their backs for every sleep, including naps and nighttime sleep.

🌹 A safe sleep environment helps reduce the risk of accidental suffocation, entrapment, and strangulation.

🌹 Parents should share a room, but not the same bed, with their infant for at least the first 6 months when possible.

🌹 Reinforcing safe sleep practices is an essential part of postpartum teaching.

🌹 Using a firm crib mattress is a key recommendation for promoting safe infant sleep.

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Answer 4

Correct Answers:

"The provider will discuss the risks of the surgery with you."

Rationale :

♦️ The healthcare provider performing the procedure is responsible for explaining the purpose, risks, benefits, and alternatives of the surgery.

♦️ This discussion allows the client to make a voluntary and informed decision before signing the consent form.

♦️ The nurse may witness the signature and verify that the client appears competent and is signing without coercion.

♦️ The nurse should also confirm that the client has had an opportunity to ask questions.

♦️ Any unanswered questions about the surgery should be referred back to the provider.

♦️ The client must understand the information well enough to make an informed choice.

♦️ The adult sibling may be present only if the client wishes, but the provider must speak directly with the client whenever the client has decision-making capacity.

♦️ The statement about the provider discussing surgical risks correctly describes the informed-consent process.

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Answer 5

Correct Answers:

Blurred vision

Rationale :

🖍️ Digoxin toxicity can cause visual disturbances, including blurred vision, yellow-green vision, and seeing halos around lights.

🖍️ These findings occur because elevated digoxin levels affect the central nervous system and retinal function.

🖍️ The nurse should also monitor for nausea, vomiting, loss of appetite, fatigue, and confusion.

🖍️ Cardiac manifestations may include bradycardia, heart block, or other dysrhythmias.

🖍️ The client’s apical pulse should be assessed before administration, and the medication should be withheld according to prescribed parameters.

🖍️ Serum digoxin levels, potassium levels, and kidney function may require monitoring because renal impairment and hypokalemia increase toxicity risk.

🖍️ Any new visual change should be reported promptly because it may signal an adverse or toxic effect.

🖍️ Blurred vision is the expected adverse effect associated with digoxin.

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Answer 6

Correct Answers:

Urine output of 40 mL in the last 2 hr.

Rationale :

📗 An output of 40 mL over 2 hours equals only 20 mL/hr, which is below the expected minimum adult urine output of approximately 30 mL/hr.

📗 Decreased urine output may indicate hypovolemia, reduced cardiac output, or inadequate renal perfusion following major surgery.

📗 A thoracotomy can involve significant fluid shifts and blood loss, increasing the risk of postoperative circulatory compromise.

📗 The nurse should assess the client’s blood pressure, heart rate, fluid balance, and catheter patency while promptly reporting the finding.

📗 Persistent oliguria can progress to acute kidney injury if inadequate perfusion is not corrected.

📗 Urine output provides an important measure of overall organ perfusion and hemodynamic stability.

📗 Early provider notification allows evaluation for fluid replacement, laboratory testing, or other treatment.

📗 Urine output of 20 mL/hr is the priority finding because it may reflect impaired circulation and renal perfusion.

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Answer 7

Correct Answers:

A client who has Alzheimer's disease

Rationale :

⚽ Reminiscence therapy encourages clients to discuss past life experiences, often using photographs, music, familiar objects, or personal stories to stimulate long-term memory.

⚽ Clients with Alzheimer's disease often retain remote memories longer than recent memories, making this therapy particularly beneficial.

⚽ Discussing meaningful past events can improve self-esteem, reduce anxiety, and promote social interaction.

⚽ Reminiscence therapy helps maintain a sense of identity and provides emotional comfort for clients with dementia.

⚽ Family members can actively participate by bringing photo albums, favorite music, or cherished keepsakes to facilitate conversations.

⚽ The nurse should encourage the client to share memories without correcting inaccurate details, as the goal is comfort rather than factual accuracy.

⚽ This therapy supports cognitive stimulation while strengthening communication between the client, family, and caregivers.

⚽ Reminiscence therapy is most appropriate for clients with Alzheimer's disease because it focuses on preserved long-term memories.

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Answer 8

Correct Answers:

Speech-language pathologist

Rationale :

👉 A speech-language pathologist (SLP) is the healthcare professional who evaluates and treats dysphagia (difficulty swallowing) following conditions such as a stroke.

👉 The SLP performs a comprehensive swallowing assessment to determine the client's risk for aspiration and recommends the safest diet consistency.

👉 The evaluation may include bedside swallowing assessments and specialized studies such as a modified barium swallow or videofluoroscopic swallowing study.

👉 The SLP teaches swallowing exercises, compensatory techniques, and safe positioning strategies to improve swallowing function.

👉 Recommendations may include thickened liquids, pureed foods, or other texture modifications to reduce aspiration risk.

👉 Early referral helps prevent complications such as aspiration pneumonia, malnutrition, and dehydration.

👉 Collaboration between the nurse and the SLP is essential to ensure the client receives safe nutrition and hydration.

👉 A speech-language pathologist is the most appropriate referral for a client experiencing difficulty swallowing after a stroke.

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Answer 9

Correct Answers:

Place the client in a private room.

Rationale :

🌸 Tuberculosis (TB) is transmitted through airborne droplet nuclei that remain suspended in the air for prolonged periods.

🌸 Clients with suspected or confirmed TB should be placed in a private airborne infection isolation room (AIIR) with negative-pressure ventilation to prevent the spread of infectious particles.

🌸 Healthcare workers should wear a fit-tested N95 respirator or higher-level respirator when entering the room.

🌸 The client should remain in the isolation room except when essential diagnostic or therapeutic procedures are required.

🌸 Prompt implementation of airborne precautions helps protect other clients, visitors, and healthcare personnel from exposure.

🌸 The nurse should also encourage respiratory hygiene, including covering the mouth when coughing and proper disposal of tissues.

🌸 Airborne precautions remain in place until the client is no longer considered infectious according to facility policy.

🌸 Placing the client in a private negative-pressure room is the priority intervention to prevent TB transmission.

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Answer 10

Correct Answers:

"Record your urination times for 24 hours before beginning the program."

Rationale :

✏️ A voiding diary establishes the client’s usual pattern of urinary frequency, urgency, leakage, and fluid intake before bladder training begins.

✏️ Recording urination times helps the healthcare team identify how long the client can normally wait between voiding episodes.

✏️ The initial toileting schedule can then be individualized according to the client’s existing pattern rather than using an arbitrary interval.

✏️ Bladder training gradually increases the time between voiding episodes to improve bladder capacity and control.

✏️ The client should also record episodes of urgency or incontinence to evaluate progress during the program.

✏️ Accurate baseline information helps determine whether the intervention is improving urinary control.

✏️ A bladder diary is commonly recommended as part of evaluating and managing urinary frequency and incontinence.

✏️ Recording urination times before starting provides the information needed to create a safe, individualized bladder-training schedule.

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QLexNursing

1 :
A nurse on a mental health unit is assisting in the care of a client who has a history of violent behavior. Which of the following actions should the nurse take?

2 :
A nurse in a rehabilitation facility is assisting with the care of a client.

Correct Answers

3 :
A nurse is reinforcing teaching about home safety with a client who is postpartum. Which of the following statements by the client indicates an understanding of the teaching?

4 :
A nurse is reinforcing teaching about informed consent with a client who is scheduled for surgery and is accompanied by their adult sibling. Which of the following statements should the nurse include in the teaching?

5 :
A nurse is collecting data from an adolescent client who takes digoxin. The nurse should monitor the client for which of the following adverse effects?

6 :
A nurse is collecting data from a client 4 hr after a thoracotomy and insertion of a chest tube. Which of the following findings should the nurse report to the provider first?

7 :
A nurse is collecting data from four clients. The nurse should anticipate the use of reminiscence therapy for which of the following clients?

8 :
A nurse is assisting with the care of a client who is experiencing difficulty swallowing following a stroke. For which of the following team members should the nurse request a referral from the provider?

9 :
A nurse is assisting with the admission of a client who has tuberculosis. Which of the following actions should the nurse take to prevent transmission of the infection?

10 :
A nurse is reinforcing teaching with a client who requires a bladder-training program for urinary incontinence. Which of the following instructions should the nurse include in the teaching?

QLexNursing

1 : A nurse on a mental health unit is assisting in the care of a client who has a history of violent behavior. Which of the following actions should the nurse take?

2 : A nurse in a rehabilitation facility is assisting with the care of a client.

Correct Answers

3 : A nurse is reinforcing teaching about home safety with a client who is postpartum. Which of the following statements by the client indicates an understanding of the teaching?

4 : A nurse is reinforcing teaching about informed consent with a client who is scheduled for surgery and is accompanied by their adult sibling. Which of the following statements should the nurse include in the teaching?

5 : A nurse is collecting data from an adolescent client who takes digoxin. The nurse should monitor the client for which of the following adverse effects?

6 : A nurse is collecting data from a client 4 hr after a thoracotomy and insertion of a chest tube. Which of the following findings should the nurse report to the provider first?

7 : A nurse is collecting data from four clients. The nurse should anticipate the use of reminiscence therapy for which of the following clients?

8 : A nurse is assisting with the care of a client who is experiencing difficulty swallowing following a stroke. For which of the following team members should the nurse request a referral from the provider?

9 : A nurse is assisting with the admission of a client who has tuberculosis. Which of the following actions should the nurse take to prevent transmission of the infection?

10 : A nurse is reinforcing teaching with a client who requires a bladder-training program for urinary incontinence. Which of the following instructions should the nurse include in the teaching?

1 :
A nurse on a mental health unit is assisting in the care of a client who has a history of violent behavior. Which of the following actions should the nurse take?

2 :
A nurse in a rehabilitation facility is assisting with the care of a client.

3 :
A nurse is reinforcing teaching about home safety with a client who is postpartum. Which of the following statements by the client indicates an understanding of the teaching?

4 :
A nurse is reinforcing teaching about informed consent with a client who is scheduled for surgery and is accompanied by their adult sibling. Which of the following statements should the nurse include in the teaching?

5 :
A nurse is collecting data from an adolescent client who takes digoxin. The nurse should monitor the client for which of the following adverse effects?

6 :
A nurse is collecting data from a client 4 hr after a thoracotomy and insertion of a chest tube. Which of the following findings should the nurse report to the provider first?

7 :
A nurse is collecting data from four clients. The nurse should anticipate the use of reminiscence therapy for which of the following clients?

8 :
A nurse is assisting with the care of a client who is experiencing difficulty swallowing following a stroke. For which of the following team members should the nurse request a referral from the provider?

9 :
A nurse is assisting with the admission of a client who has tuberculosis. Which of the following actions should the nurse take to prevent transmission of the infection?

10 :
A nurse is reinforcing teaching with a client who requires a bladder-training program for urinary incontinence. Which of the following instructions should the nurse include in the teaching?