Question

A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?

Answer 1

Correct Answers:

“I will need assistance with bathing."

Rationale :

🔷 Occupational therapists help clients improve independence with activities of daily living, such as bathing, dressing, grooming, cooking, and using adaptive equipment.

🔷 Rheumatoid arthritis can cause joint pain, stiffness, swelling, decreased hand strength, and limited mobility, making self-care tasks difficult.

🔷 A client who needs help with bathing may benefit from adaptive devices such as a shower chair, grab bars, long-handled sponge, handheld showerhead, or modified bathroom setup.

🔷 Occupational therapy also teaches joint-protection techniques and energy-conservation strategies to reduce pain and fatigue during daily activities.

🔷 This referral supports safety, independence, and prevention of falls or injury during personal care.

❌ “I'm having difficulty climbing the stairs at my house.”

🔷 Difficulty climbing stairs is more closely related to mobility, gait, strength, and endurance needs.

🔷 This concern is more appropriate for physical therapy, which focuses on ambulation, strengthening, and mobility training.

❌ “I need some help planning my meals to maintain my weight.”

🔷 Meal planning and weight maintenance are best addressed by a dietitian.

🔷 The dietitian can help the client choose nutrient-dense foods that support health and weight goals.

❌ “I am tired of having pain in my joints all the time.”

🔷 Chronic joint pain should be addressed through pain management, medication evaluation, and provider follow-up.

🔷 Although occupational therapy may teach joint protection, the most direct referral indication here is difficulty with self-care activity.

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Answer 2

Correct Answers:

Proceed with treatment without obtaining written consent.

Rationale :

🟠 In an emergency, care can be provided under implied consent when the client is unable to give informed consent.

🟠 This client is disoriented and has a cardiac arrhythmia, which indicates a potentially life-threatening condition requiring immediate treatment.

🟠 Delaying care to obtain written consent could place the client at risk for serious harm or death.

🟠 Emergency treatment is legally and ethically permitted when rapid intervention is necessary to preserve life or prevent deterioration.

🟠 The nurse should provide urgent care, document the client’s condition, and follow facility policy after stabilization.

❌ Contact the client's next of kin to obtain consent for treatment.

🟠 Contacting family may be appropriate later, but it should not delay emergency care.

🟠 The client’s unstable condition requires immediate intervention under implied consent.

❌ Notify risk management before initiating treatment.

🟠 Risk management does not need to approve emergency lifesaving care before treatment begins.

🟠 Waiting for risk management would delay necessary intervention and increase client risk.

❌ Have the client sign a consent for treatment.

🟠 The client is disoriented and may not have decision-making capacity at that moment.

🟠 A consent signed by a confused client would not represent valid informed consent.

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Answer 3

Correct Answers:

Oxygen tank
Obturator
Pipe cleaners

Rationale :

🟣 Oxygen tank

🟣 A client with a newly placed tracheostomy may need an oxygen source at home depending on oxygen saturation, respiratory status, and provider orders.

🟣 Oxygen may be delivered through a tracheostomy collar to maintain adequate oxygenation.

🟣 The nurse should assess whether the client needs oxygen equipment, humidification, and backup supplies before discharge.

🟣 Obturator

🟣 The obturator is essential because it is used to guide reinsertion of the tracheostomy tube if the tube becomes dislodged.

🟣 It should be kept near the client at all times for emergency replacement.

🟣 The client and caregiver should be taught how and when the obturator is used, especially for accidental decannulation.

🟣 Pipe cleaners

🟣 Pipe cleaners may be used to clean the inner cannula of some reusable tracheostomy tubes.

🟣 They help remove mucus and secretions that can block airflow.

🟣 Keeping the inner cannula clean helps prevent airway obstruction and supports effective breathing.

❌ Petroleum jelly

🟣 Petroleum-based products are not recommended around oxygen or tracheostomy care because they can be unsafe and may irritate tissue.

🟣 Water-soluble lubricant is preferred when lubrication is needed.

❌ Cotton balls

🟣 Cotton balls should not be used around a tracheostomy because fibers can loosen and enter the airway.

🟣 Tracheostomy care should use appropriate sterile or clean supplies according to facility and home-care instructions.

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Answer 4

Correct Answers:

Gonorrhea

Rationale :

🟢 Gonorrhea is a reportable sexually transmitted infection that must be reported to the health department.

🟢 Reporting allows public health officials to track infection rates, monitor outbreaks, and support partner notification and treatment.

🟢 Gonorrhea can cause pelvic inflammatory disease, infertility, epididymitis, disseminated infection, and neonatal complications if untreated.

🟢 Early reporting and treatment help reduce transmission in the community.

🟢 The nurse should follow state and local reporting laws and ensure the client receives education about treatment, partner therapy, and prevention.

❌ Trichomoniasis

🟢 Trichomoniasis is a sexually transmitted infection, but it is not typically the standard reportable infection in this type of question.

🟢 It is treated with prescribed antimicrobial therapy and partner treatment education.

❌ Human papillomavirus

🟢 HPV is common and associated with genital warts and cervical cancer risk.

🟢 It is generally managed through vaccination, screening, and follow-up rather than routine health department reporting.

❌ Candidiasis

🟢 Candidiasis is a fungal infection and is not classified as a reportable sexually transmitted infection.

🟢 It may occur from altered vaginal flora, antibiotic use, pregnancy, diabetes, or immune changes.

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Answer 5

Correct Answers:

Remove the client's restraints every 2 hr.

Rationale :

🔵 Restraints must be removed at least every 2 hours to assess skin, circulation, range of motion, comfort, and continued need for restraint use.

🔵 Frequent release helps prevent skin breakdown, nerve injury, impaired circulation, stiffness, and emotional distress.

🔵 The nurse or trained staff should check the client’s pulses, color, temperature, sensation, and movement during restraint care.

🔵 Restraints should be used only when less restrictive interventions have failed and the client’s safety is at risk.

🔵 Ongoing monitoring and documentation are required to protect client safety and legal rights.

❌ Allow 1 fingerbreadth between the restraint and the client's wrists.

🔵 The restraint should allow two fingerbreadths between the restraint and the client’s wrist.

🔵 One fingerbreadth is too tight and can impair circulation or cause skin injury.

❌ Attach the restraints to the fixed portion of the frame of the client's bed.

🔵 Restraints should be attached to the movable portion of the bed frame, not the side rails.

🔵 This prevents injury when the bed position is changed and keeps the restraint secure.

❌ Secure the client's restraints with a square knot.

🔵 Restraints should be secured with a quick-release knot, not a square knot.

🔵 A quick-release knot allows rapid removal in an emergency.

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Answer 6

Correct Answers:

Provide the client with written information in their spoken language.

Rationale :

🔷 The nurse should provide teaching in a way the client can understand clearly and safely.

🔷 Written information in the client’s spoken language helps support accurate medication teaching and reinforces verbal instructions.

🔷 Medication education must be understandable because errors can occur if the client misunderstands dosage, timing, adverse effects, or safety precautions.

🔷 The nurse should also use a qualified medical interpreter when verbal teaching is needed.

🔷 This approach supports client safety, informed decision-making, and culturally appropriate care.

❌ Have the client's family member who is present interpret.

🔷 Family members should not be used as interpreters for medical teaching unless it is an emergency and no interpreter is available.

🔷 They may misunderstand medical information, omit details, or change the message.

❌ Use medical terminology while explaining the medications.

🔷 Medical terminology can confuse the client and increase the risk for misunderstanding.

🔷 Teaching should use clear, simple, nontechnical language.

❌ Speak very slowly during the teaching session.

🔷 Speaking slowly does not solve the language barrier.

🔷 The client may still be unable to understand the information if it is not provided in their language.

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Answer 7

Correct Answers:

Encourage the client to research Crohn's disease on websites that have a ".gov" address.

Rationale :

🟠 Clients should be guided toward reliable, evidence-based health information.

🟠 Websites ending in “.gov” are usually government-supported and provide health information that is reviewed for accuracy.

🟠 Crohn’s disease is a chronic inflammatory bowel disease, so the client needs trustworthy education about symptoms, medications, diet, flare prevention, and follow-up care.

🟠 Reliable sources help the client avoid unsafe advice, misinformation, or unproven treatments.

🟠 Encouraging accurate learning supports self-management and informed participation in care.

❌ Ask a licensed practical nurse to explain Crohn’s disease to the client.

🟠 Client teaching about a new diagnosis should be initiated and reinforced by the RN.

🟠 An LPN may reinforce teaching, but the RN is responsible for primary education.

❌ Suggest that the client read articles that recommend specific treatments for Crohn's disease.

🟠 Articles promoting specific treatments may be biased or inaccurate.

🟠 The client should use evidence-based sources and discuss treatment choices with the provider.

❌ Recommend podcasts that discuss Crohn's disease to the client.

🟠 Podcasts vary widely in accuracy and may not be medically reviewed.

🟠 They should not replace reliable written education from credible health sources.

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Answer 8

Correct Answers:

A client who has active bleeding from a puncture wound of the left groin area

Rationale :

🟣 Active bleeding from the groin area is the highest priority because the femoral vessels are located there.

🟣 Injury to the femoral artery or vein can cause rapid, life-threatening blood loss.

🟣 This client is at immediate risk for hemorrhagic shock, decreased tissue perfusion, and death if bleeding is not controlled quickly.

🟣 The nurse should apply direct pressure, activate emergency support, and prepare for rapid intervention.

🟣 Under priority frameworks, uncontrolled bleeding is an immediate threat to circulation and requires urgent action.

❌ A client who reports shortness of breath and left neck and shoulder pain.

🟣 This is concerning for possible cardiac ischemia and requires prompt assessment.

🟣 However, active groin bleeding is more immediately life-threatening due to rapid blood loss.

❌ A client who has a raised red skin rash on their arms, neck, and face.

🟣 A rash may indicate an allergic reaction and should be assessed for airway involvement.

🟣 Without signs of airway compromise, it is not the highest priority.

❌ A client who reports right-sided flank pain and is diaphoretic.

🟣 Flank pain with diaphoresis can indicate renal colic, infection, or another acute condition.

🟣 It is urgent, but it does not take priority over uncontrolled bleeding.

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Answer 9

Correct Answers:

Social worker

Rationale :

🟢 A social worker helps clients and families access financial resources, community programs, insurance assistance, and medical equipment support.

🟢 The parent’s main concern is not lack of knowledge about the nebulizer but inability to afford the prescribed equipment.

🟢 Social workers can connect the family with durable medical equipment programs, charity resources, Medicaid support, or payment assistance.

🟢 For a toddler with asthma, having the nebulizer available at home is important for timely treatment of bronchospasm and prevention of worsening respiratory distress.

🟢 This referral supports safe discharge planning and reduces the risk of preventable emergency visits.

❌ Pharmacist

🟢 A pharmacist can teach medication use, side effects, and safe storage.

🟢 However, the primary issue is financial access to equipment, which is best handled by social services.

❌ Respiratory therapist

🟢 A respiratory therapist can teach nebulizer technique and respiratory care.

🟢 The therapist does not primarily arrange financial assistance for equipment.

❌ Child protective services

🟢 Child protective services are not appropriate simply because a parent cannot afford equipment.

🟢 The nurse should first connect the family with support resources rather than assume neglect.

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Answer 10

Correct Answers:

Requesting a referral for the client to attend reminiscent therapy sessions

Rationale :

🔵 Client advocacy means acting to support the client’s needs, rights, preferences, safety, and quality of life.

🔵 Requesting a referral for reminiscence therapy helps the client access a beneficial supportive service.

🔵 Reminiscence therapy can help clients with early Alzheimer’s disease maintain identity, communication, emotional connection, and memory stimulation.

🔵 Advocacy involves connecting the client with appropriate resources rather than only completing routine nursing care.

🔵 This action promotes person-centered care and supports the client’s psychosocial well-being.

❌ Performing an updated cognitive assessment on the client

🔵 Cognitive assessment is an important nursing responsibility.

🔵 However, it is assessment rather than advocacy because it does not directly secure an additional service or resource for the client.

❌ Providing assistance for the client when ambulating down the hall

🔵 Assisting with ambulation promotes safety and meets a physical care need.

🔵 This is routine nursing care rather than an advocacy action.

❌ Reorienting the client several times throughout the day

🔵 Reorientation can be helpful for confusion and memory impairment.

🔵 However, it is a direct nursing intervention rather than advocating for resources or services.

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QLexNursing

1 :
A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?

2 :
A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

3 :
A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home? (Select all that apply.)

4 :
A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department?

5 :
A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

6 :
A nurse is teaching a client who speaks a different language than the nurse about medications. Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who has a new diagnosis of Crohn's disease and is interested in learning more about their condition. Which of the following actions should the nurse take?

8 :
A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

9 :
A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states that they are unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?

10 :
A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?

QLexNursing

1 : A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?

2 : A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

3 : A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home? (Select all that apply.)

4 : A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department?

5 : A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

6 : A nurse is teaching a client who speaks a different language than the nurse about medications. Which of the following actions should the nurse take?

7 : A nurse is caring for a client who has a new diagnosis of Crohn's disease and is interested in learning more about their condition. Which of the following actions should the nurse take?

8 : A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

9 : A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states that they are unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?

10 : A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?

1 :
A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?

2 :
A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

3 :
A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home? (Select all that apply.)

4 :
A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department?

5 :
A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

6 :
A nurse is teaching a client who speaks a different language than the nurse about medications. Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who has a new diagnosis of Crohn's disease and is interested in learning more about their condition. Which of the following actions should the nurse take?

8 :
A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

9 :
A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states that they are unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?

10 :
A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?