Question

A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

Answer 1

Correct Answers:

Plan to remove the restraints as soon as the client is calm.

Rationale :

🔷 Restraints are used only as a last resort and must be discontinued as soon as the client can maintain safety.

🔷 Client rights and safety take priority, and continued use without cause may be a legal violation.

🔷 Nurses must assess and document behavior every 15 minutes to determine the earliest time to remove restraints.

🔷 Federal guidelines mandate restraint use to be time-limited and justified by the client's behavior.

🔷 De-escalation and therapeutic communication should resume immediately once the client is stable.

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Answer 2

Correct Answers:

Decreased hemoglobin

Rationale :

🔶 Cigarette smoking increases carbon monoxide levels, which binds with hemoglobin, reducing oxygen-carrying capacity.

🔶 Chronic exposure leads to functional anemia, as hemoglobin cannot effectively bind to oxygen.

🔶 This results in tissue hypoxia and compensatory polycythemia, but functional hemoglobin remains low.

🔶 Clients may experience fatigue and increased cardiovascular strain due to reduced oxygen delivery.

🔶 Monitoring hemoglobin and hematocrit is essential in long-term smokers.

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Answer 3

Correct Answers:

"I might have short-term memory loss after the procedure."

Rationale :

💎 Short-term memory loss is a common and expected side effect of electroconvulsive therapy (ECT).

💎 The memory effects are usually temporary and resolve within days to weeks.

💎 ECT is used to treat severe depression and refractory mental illness, especially when other treatments fail.

💎 Clients are under general anesthesia during the procedure, and monitoring is continuous.

💎 Pre- and post-procedure education includes discussing cognitive effects.

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Answer 4

Correct Answers:

Maintain the client in high-Fowler's position.

Rationale :

🟦 High-Fowler’s positioning facilitates lung expansion, which improves oxygenation.

🟦 Heart failure often leads to pulmonary congestion, and upright posture helps reduce preload.

🟦 Crackles indicate fluid accumulation in the alveoli, a classic sign of left-sided HF.

🟦 This positioning also reduces the work of breathing, decreasing dyspnea.

🟦 It is a priority intervention before administering medications.

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Answer 5

Correct Answers:

This medication prevents your baby from developing bleeding problems."

Rationale :

🟨 Phytonadione (Vitamin K) is essential for clotting factor synthesis in newborns.

🟨 Newborns lack intestinal flora at birth, which produces Vitamin K.

🟨 Without supplementation, they are at risk for hemorrhagic disease of the newborn.

🟨 The injection is typically given within the first hour after birth.

🟨 It supports effective coagulation until the infant can produce Vitamin K naturally.

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Answer 6

Correct Answers:

Reduced fat in the stools

Rationale :

🔵 Pancrelipase is a pancreatic enzyme replacement that helps break down fats, proteins, and carbohydrates.

🔵 Children with cystic fibrosis have pancreatic insufficiency, leading to steatorrhea (fatty, foul-smelling stools).

🔵 Effective enzyme therapy results in better digestion of dietary fats, reducing the fat content in stools.

🔵 Improved stool consistency and reduced gastrointestinal symptoms like bloating and cramping indicate effectiveness.

🔵 This allows for improved nutrient absorption, including fat-soluble vitamins (A, D, E, K).

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Answer 7

Correct Answers:

Semi-Fowler's

Rationale :

🔴 The semi-Fowler’s position supports neck alignment and reduces strain on the surgical site following thyroidectomy.

🔴 This position minimizes the risk of airway obstruction from postoperative edema or bleeding.

🔴 It promotes adequate ventilation, important due to potential swelling around the neck and trachea.

🔴 The head should be supported with pillows, keeping it midline to avoid tension on the sutures.

🔴 Airway management is a priority due to the proximity of the surgical site to the trachea.

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Answer 8

Correct Answers:

Loss of taste

Rationale :

🟡 External radiation for throat cancer can damage taste buds and salivary glands, leading to dysgeusia or ageusia.

🟡 Clients often report metallic or altered taste as one of the first changes during head and neck radiation therapy.

🟡 This is due to the effects of radiation on the oral mucosa and cranial nerves involved in taste.

🟡 Taste changes may persist during and after treatment, sometimes for weeks or months.

🟡 Nutritional support may be needed due to decreased appetite and altered oral intake.

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Answer 9

Correct Answers:

Fruity breath odor

Rationale :

🟣 Fruity or acetone breath is a hallmark sign of diabetic ketoacidosis (DKA). 🟣 It results from the buildup of ketone bodies, specifically acetone, in the blood and exhaled air. 🟣 DKA occurs when insulin is insufficient, leading to fat breakdown and ketoacidosis. 🟣 Other findings include Kussmaul respirations, dehydration, and hyperglycemia. 🟣 Immediate intervention is needed to prevent worsening acidosis and coma.

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Answer 10

Correct Answers:

Place a pillow under the child's head.

Rationale :

⚫ During a tonic-clonic seizure, priority is to protect the client from injury without restricting movement.

⚫ Placing a pillow or soft object under the head prevents head trauma from the uncontrolled movements.

⚫ The nurse should maintain a side-lying position, if possible, to prevent aspiration.

⚫ Objects should never be placed in the mouth, and restraints must be avoided.

⚫ Document the duration and characteristics of the seizure once it ends.

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QLexNursing

1 :
A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

2 :
A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching?

3 :
A nurse in an Inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the client indicates an understanding of the procedure?

4 :
A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?

5 :
A nurse is caring for a client who asks why her newborn is receiving a phytonadione injection. Which of the following statements should the nurse make?

6 :
A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

7 :
A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?

8 :
A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

9 :
A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

10 :
A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

2 : A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching?

3 : A nurse in an Inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the client indicates an understanding of the procedure?

4 : A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?

5 : A nurse is caring for a client who asks why her newborn is receiving a phytonadione injection. Which of the following statements should the nurse make?

6 : A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

7 : A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?

8 : A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

9 : A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

10 : A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

1 :
A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

2 :
A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching?

3 :
A nurse in an Inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the client indicates an understanding of the procedure?

4 :
A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?

5 :
A nurse is caring for a client who asks why her newborn is receiving a phytonadione injection. Which of the following statements should the nurse make?

6 :
A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

7 :
A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?

8 :
A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

9 :
A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

10 :
A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?