Question

A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

Answer 1

Correct Answers:

Use a sheet when repositioning the client onto his side.

Rationale :

🔷 A client with a thoracic spine injury is at risk for spinal instability and further neurologic injury.

🔷 Logrolling using a sheet helps maintain spinal alignment and prevents twisting of the spine during movement.

🔷 This technique requires coordination and sufficient staff to stabilize the head, shoulders, hips, and legs in alignment.

🔷 Using a draw sheet also reduces shear and friction, which is important for immobile clients.

🔷 Immobilization collars are typically for cervical spine injuries, not thoracic.

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Answer 2

Correct Answers:

"Fertility returns immediately after removal of the device."

Rationale :

🔶 Intrauterine devices (IUDs), both hormonal and copper types, allow immediate return to fertility once removed.

🔶 This makes them a popular choice for women planning future pregnancies.

🔶 Pain during intercourse is not an expected side effect; it requires evaluation.

🔶 Replacement frequency depends on the type: hormonal IUDs may last 3–7 years; copper IUDs can last up to 10 years.

🔶 Weight changes do not affect the function of IUDs.

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Answer 3

Correct Answers:

Reinforce orientation to time, place, and person.
Give the client one simple direction at a time.
Establish eye contact when communicating with the client.

Rationale :

Reinforce orientation to time, place, and person

🔵 Providing frequent orientation helps reduce confusion and supports reality-based thinking for clients with dementia.

🔵 This approach can lower anxiety and promote a sense of safety in unfamiliar environments.

🔵 Simple, consistent reminders reinforce cognitive functioning and enhance cooperation during care.

Give the client one simple direction at a time

🔵 Clients with dementia often have impaired short-term memory and cognitive processing, making complex directions overwhelming.

🔵 Offering one-step instructions promotes understanding and success in task completion.

🔵 This strategy helps maintain independence and reduces frustration for the client.

Establish eye contact when communicating with the client

🔵 Maintaining eye contact conveys attention, respect, and presence, which are essential in building trust.

🔵 It also helps the client focus on the conversation and may improve comprehension, especially when verbal skills are diminished.

🔵 Eye contact serves as a non-verbal cue that reinforces connection and attentiveness during interactions.

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Answer 4

Correct Answers:

Standard

Rationale :

🔶 Erythema migrans is the hallmark rash of Lyme disease, caused by Borrelia burgdorferi via tick bite.

🔶 Lyme disease is not transmitted from person to person, so standard precautions are sufficient.

🔶 There’s no need for droplet, airborne, or contact precautions unless another infection is suspected.

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Answer 5

Correct Answers:

Diaphoresis
Tremors
Inability to concentrate

Rationale :

Diaphoresis

🟣 Diaphoresis, or excessive sweating, is a classic sign of hypoglycemia, triggered by activation of the sympathetic nervous system in response to falling glucose levels.

🟣 It serves as one of the body’s early warning signals and may be the first observable symptom in a client with hypoglycemia.

🟣 Recognizing diaphoresis early is critical to intervening before neurological symptoms develop.

Tremors

🟣 Tremors occur due to adrenergic stimulation as the body tries to compensate for low blood glucose.

🟣 This symptom reflects altered neuromuscular function, which often accompanies other sympathetic signs like tachycardia and anxiety.

🟣 It is one of the hallmark symptoms that should prompt immediate glucose assessment and intervention.

Inability to concentrate

🟣 Glucose is the brain’s primary energy source, and low levels impair cognitive function, leading to difficulty concentrating.

🟣 This neuroglycopenic symptom can manifest subtly, making it essential for nurses to recognize mental status changes as early signs.

🟣 Addressing this promptly helps prevent progression to more severe complications like confusion, seizures, or coma.

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Answer 6

Correct Answers:

Provide the client with a stool softener.

Rationale :

🔶 Thrombocytopenia increases the risk of bleeding.

🔶 Preventing constipation reduces straining, which could cause rectal bleeding or hemorrhoids.

🔶 Stool softeners promote easier bowel movements and reduce trauma.

🔶 Raw vegetables or flowers are more relevant for neutropenia.

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Answer 7

Correct Answers:

Administer activated charcoal.

Rationale :

🔷 Activated charcoal is used to limit absorption of salicylates in the GI tract.

🔷 It's most effective if administered within 1–2 hours of ingestion.

🔷 Chelation and deferoxamine are for heavy metal/iron poisoning.

🔷 Gastric lavage is used less frequently and only in life-threatening cases.

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Answer 8

Correct Answers:

Determine if the tablets are scored.

Rationale :

🔶 Only scored tablets are safe to cut, as they are designed to provide equal distribution of medication.

🔶 Cutting unscored tablets may affect dose accuracy or release mechanism.

🔶 Extended-release, enteric-coated tablets should never be split unless specified.

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Answer 9

Correct Answers

Blank 1 Correct Option: Thoughts of self-harm
Blank 2 Correct Option: Hopelessness

Rationale :

Thoughts of self-harm

🟤 The client demonstrates multiple risk factors for suicidal ideation, including recent personal losses (relationship and job), social withdrawal, and verbal expressions of despair.

🟤 Statements such as “My life is a mess” and refusal to eat reflect a deep sense of emotional pain and helplessness, which are warning signs of potential self-harm or suicidal behavior.

🟤 In mental health nursing, it's critical to assess for suicidal intent when clients exhibit depression combined with hopelessness and major life stressors.

Hopelessness

🟤 The client’s flat affect, tearfulness, refusal to eat, and self-defeating statements indicate hopelessness, a major symptom of clinical depression.

🟤 Hopelessness is a strong predictor of suicidal thoughts and should be treated as a psychiatric emergency.

🟤 It reflects the client's belief that the future holds no possibility for improvement or change, which is a key red flag in risk assessments.

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Answer 10

Correct Answers

Blank 1 Correct Option: Opioid intoxication
Blank 2 Correct Option: Pupil characteristics

Rationale :

Opioid intoxication

🔴 The client was found unresponsive, had a needle in the antecubital space, and responded to naloxone, which is a specific opioid antagonist—confirming opioid overdose.

🔴 Clinical signs including bradypnea (RR 10/min), drowsiness, and miotic (pinpoint) pupils are hallmark indicators of opioid toxicity.

🔴 Additional signs such as decreased bowel sounds and a history of prior opioid-related incidents further support the diagnosis of opioid intoxication.

Pupil characteristics

🔴 The presence of miotic pupils (constricted pupils) is one of the most reliable physical findings associated with opioid toxicity.

🔴 This symptom results from opioid-induced parasympathetic stimulation and is often used in the clinical setting to differentiate opioid intoxication from other types of altered mental status.

🔴 While other symptoms may vary, pinpoint pupils are considered a classic diagnostic clue when evaluating suspected opioid overdose.

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QLexNursing

1 :
A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

2 :
A nurse is providing teaching to a client who is scheduled for the insertion of an intrauterine device (IUD). Which of the following statements should the nurse include?

3 :
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

4 :
A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

5 :
A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

6 :
A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include?

7 :
A nurse is caring for a child who ingested a large amount of aspirin. Which of the following interventions should the nurse anticipate?

8 :
A home health nurse is verifying a client's prescribed medications and notes that one medication dose was decreased by half. The client asks the nurse if they can cut the tablets in half. Which of the following actions should the nurse take?

9 :
A nurse on a mental health unit is caring for a client.

Correct Answers

10 :
A nurse is caring for a client in the emergency department.

Correct Answers

QLexNursing

1 : A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

2 : A nurse is providing teaching to a client who is scheduled for the insertion of an intrauterine device (IUD). Which of the following statements should the nurse include?

3 : A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

4 : A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

5 : A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

6 : A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include?

7 : A nurse is caring for a child who ingested a large amount of aspirin. Which of the following interventions should the nurse anticipate?

8 : A home health nurse is verifying a client's prescribed medications and notes that one medication dose was decreased by half. The client asks the nurse if they can cut the tablets in half. Which of the following actions should the nurse take?

9 : A nurse on a mental health unit is caring for a client.

Correct Answers

10 : A nurse is caring for a client in the emergency department.

Correct Answers

1 :
A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

2 :
A nurse is providing teaching to a client who is scheduled for the insertion of an intrauterine device (IUD). Which of the following statements should the nurse include?

3 :
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

4 :
A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

5 :
A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

6 :
A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include?

7 :
A nurse is caring for a child who ingested a large amount of aspirin. Which of the following interventions should the nurse anticipate?

8 :
A home health nurse is verifying a client's prescribed medications and notes that one medication dose was decreased by half. The client asks the nurse if they can cut the tablets in half. Which of the following actions should the nurse take?

9 :
A nurse on a mental health unit is caring for a client.

10 :
A nurse is caring for a client in the emergency department.