Question

A nurse is reinforcing teaching with a newly licensed nurse about adverse effects of medications. The nurse should include that which of the following medications can cause constipation? (Select all that apply.)

Answer 1

Correct Answers:

Opioid narcotics
Anticholinergics/antispasmodics
Iron supplements

Rationale :

⭐ Opioid narcotics Opioids slow peristalsis, causing stool to move slowly through the bowel.

⭐ Slowed peristalsis leads to increased water absorption, making stool hard and dry.

⭐ Opioids decrease intestinal secretions, further reducing stool moisture.

⭐ The reduced motility increases the risk of straining and impaction.

⭐ Anticholinergics/antispasmodics Anticholinergics block acetylcholine, which slows gastrointestinal motility.

⭐ Slower motility increases water reabsorption, leading to dry stool.

⭐ They reduce smooth muscle contraction, making defecation more difficult.

⭐ These effects particularly worsen constipation in older adults.

⭐ Iron supplements Iron causes stool to become hard and dense, making passage difficult.

⭐ Iron irritates the intestinal mucosa, slowing movement.

⭐ It commonly leads to dark, firm stools, which are harder to expel.

⭐ Iron is one of the most frequent non-opioid causes of drug-induced constipation.

Magnesium-containing antacids

⭐ Magnesium antacids cause diarrhea, not constipation.

⭐ They increase intestinal motility and water retention in the bowel.

Antibiotics

⭐Antibiotics commonly cause diarrhea due to altered gut flora.

⭐They increase bowel activity rather than slowing it.

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Answer 2

Correct Answers:

Increase the client's fluid intake.

Rationale :

🌸 Increased fluids help soften stool consistency, easing passage.

🌸 Adequate hydration promotes bowel motility, especially in immobile clients.

🌸 Bed-rest slows peristalsis, making fluids essential to counter decreased movement.

🌸 Hydration prevents hard, impacted stool, a common problem in immobility.

Low-fiber diet

🌸Fiber should be increased, not reduced, to treat constipation.

Cold fluids

🌸 Cold liquids can slow intestinal motility, worsening constipation.

Mineral oil prescription

🌸 Mineral oil risks aspiration, especially in older adults.

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Answer 3

Correct Answers:

Partial-thickness skin loss with red tissue in wound bed.

Rationale :

🔷 Stage 2 pressure injury involves partial-thickness loss of skin.

🔷 The wound bed appears pink/red, moist, and shallow.

🔷 May present as a blister (intact or ruptured).

🔷 No exposure of fat, muscle, or bone, keeping it distinct from later stages.

Visible adipose tissue

🔷This indicates stage 3, not stage 2.

Intact skin with erythema

🔷This describes stage 1, not stage 2.

Visible bone

🔷This indicates stage 4, not stage 2.

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Answer 4

Correct Answers:

A deep crater without visible bone, tendon, or muscle

Rationale :

🔶 Stage 3 pressure injuries show full-thickness skin loss.

🔶 Adipose tissue may be visible, but deeper structures are NOT exposed.

🔶 The wound often appears as a deep crater.

🔶 Slough may be present but not obscuring depth.

🔶 No visible bone, tendon, or muscle, differentiating from stage 4.

Full-thickness to supporting structures

🔶 This describes stage 4, not stage 3.

Unblanchable erythema

🔶 This describes stage 1.

Ruptured blister

🔶This is a stage 2 injury.

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Answer 5

Correct Answers:

"Increase your daily fluid intake."

Rationale :

💠 Fluids help soften stool, improving ease of passage.

💠 Hydration improves peristaltic movement, reducing constipation.

💠 Increasing fluids prevents hard, compact stool formation.

💠 Clients with constipation benefit from both fluids and fiber.

Defecate at different times

💠Regular timing is better — irregular attempts worsen constipation patterns.

Reduce activity

💠Activity should be increased to promote bowel motility.

Low-fiber diet

💠 Fiber should be increased, not reduced.

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Answer 6

Correct Answers:

Reposition the client at least every 2 hr.

Rationale :

💎 Repositioning reduces pressure duration, the biggest cause of tissue breakdown.

💎 Changing position improves circulation to bony prominences.

💎 It reduces risk of hypoxia and cell death under pressure points.

💎 Standard preventive guideline: turn every 2 hours.

💎 Essential for clients on bed rest to prevent pressure injuries.

Keep skin moist

💎Moisture increases risk of breakdown and shearing.

Elevate head of bed

💎This increases shear on the sacrum.

Massage bony prominences

💎Massaging can damage capillaries in fragile skin.

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Answer 7

Correct Answers:

The client's need for assistance with ADLs.
The condition of the client's skin.
The client's ability to sit.

Rationale :

Assistance with ADLs ADLs reflect functional mobility, a core component of mobility assessment.

🌟 Evaluating independence helps determine fall risk.

🌟 ADL needs correlate with muscle strength and joint function.

🌟 Helps guide the plan of care for mobility improvement.

🌟 Condition of skin Skin integrity reflects pressure tolerance and mobility.

🌟 Immobility increases risk of breakdown, making skin assessment essential.

🌟 Skin assessment reveals circulatory status.

🌟 Identifying redness early prevents pressure injury progression.

🌟 Ability to sit Sitting balance indicates core strength.

🌟 Ability to sit shows neuromuscular coordination and stability.

🌟 This is a primary step before attempting standing or ambulation.

🌟 Helps predict safe mobility level.

Health literacy

🌟Not related to mobility performance.

Daily calcium intake

🌟Does not measure actual mobility or movement ability.

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Answer 8

Correct Answers:

Ask the client to place their feet on the floor.

Rationale :

🔵 Placing feet on the floor ensures ground stability before any movement.

🔵 This prevents falls due to orthostatic dizziness.

🔵 It allows assessment of lower-extremity strength.

🔵 Safe positioning reduces risk of instability during the next steps.

March in place

🔵 Too advanced — must assess stability first.

Stand for 5 seconds

🔵 Standing before foot placement increases fall risk.

Sit at edge of bed

🔵This is appropriate but not the first step.

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Answer 9

Correct Answers:

Increased joint stiffness

Rationale :

🟠 Aging decreases synovial fluid, causing joint stiffness.

🟠 Cartilage wears down, limiting range of motion.

🟠 Ligaments lose elasticity, reducing flexibility.

🟠 Older adults often report stiffness after immobility or waking.

🟠 This is a hallmark of musculoskeletal aging.

Increased balance

🟠Aging usually reduces balance.

Increased muscle mass

🟠Aging causes muscle loss (sarcopenia).

Increased bone calcification

🟠 Aging leads to bone loss, not more calcification.

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Answer 10

Correct Answers:

A client who is alert and responsive and eats 25% of each meal.

Rationale :

🟡 Eating only 25% of meals indicates poor nutrition, a major pressure-injury risk.

🟡 Malnutrition reduces tissue repair ability and skin resilience.

🟡 Low protein intake decreases collagen formation, weakening skin.

🟡 Mobility does not fully compensate for nutritional deficiency.

🟡 Poor nutrition is one of the strongest predictors of pressure injury.

Unresponsive client changing position occasionally

🟡 Occasional movement lowers risk more than poor nutrition.

Client walking occasionally

🟡Ambulation significantly reduces pressure-injury risk.

Independent client on enteral feeding

🟡Adequate nutrition decreases risk despite feeding route.

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QLexNursing

1 :
A nurse is reinforcing teaching with a newly licensed nurse about adverse effects of medications. The nurse should include that which of the following medications can cause constipation? (Select all that apply.)

2 :
A nurse is assisting with the care of a client who is on bed-rest and is experiencing constipation. Which of the following interventions should the nurse implement?

3 :
A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

4 :
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

5 :
A nurse is assisting with teaching a client who has constipation. Which of the following statements should the nurse include?

6 :
A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

7 :
A nurse is assisting in performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment? (Select all that apply.)

8 :
A nurse is collecting data on the mobility of a client. Which of the following actions should the nurse take first?

9 :
A nurse is collecting data on an older adult client who is experiencing age-related changes. Which of the following findings should the nurse expect?

10 :
A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?

QLexNursing

1 : A nurse is reinforcing teaching with a newly licensed nurse about adverse effects of medications. The nurse should include that which of the following medications can cause constipation? (Select all that apply.)

2 : A nurse is assisting with the care of a client who is on bed-rest and is experiencing constipation. Which of the following interventions should the nurse implement?

3 : A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

4 : A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

5 : A nurse is assisting with teaching a client who has constipation. Which of the following statements should the nurse include?

6 : A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

7 : A nurse is assisting in performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment? (Select all that apply.)

8 : A nurse is collecting data on the mobility of a client. Which of the following actions should the nurse take first?

9 : A nurse is collecting data on an older adult client who is experiencing age-related changes. Which of the following findings should the nurse expect?

10 : A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?

1 :
A nurse is reinforcing teaching with a newly licensed nurse about adverse effects of medications. The nurse should include that which of the following medications can cause constipation? (Select all that apply.)

2 :
A nurse is assisting with the care of a client who is on bed-rest and is experiencing constipation. Which of the following interventions should the nurse implement?

3 :
A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

4 :
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

5 :
A nurse is assisting with teaching a client who has constipation. Which of the following statements should the nurse include?

6 :
A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

7 :
A nurse is assisting in performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment? (Select all that apply.)

8 :
A nurse is collecting data on the mobility of a client. Which of the following actions should the nurse take first?

9 :
A nurse is collecting data on an older adult client who is experiencing age-related changes. Which of the following findings should the nurse expect?

10 :
A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?