Question

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

Answer 1

Correct Answers:

A client who is unresponsive to verbal commands and changes position occasionally.

Rationale :

🛏️ Immobility is the greatest risk factor for pressure injury development, and clients who are unresponsive cannot reliably reposition themselves or communicate discomfort.

🛏️ Occasional changes in position are insufficient to relieve pressure over bony prominences, increasing the risk of tissue ischemia and skin breakdown.

🛏️ This client's reduced sensory perception, limited mobility, and likely compromised nutritional intake or perfusion all contribute to stage 1 or deeper pressure injury risk.

🛏️ Frequent repositioning, skin assessments, and pressure-relieving devices are essential preventive interventions.

🛏️ Other clients listed have some combination of mobility or adequate nutrition, which reduces their risk.

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Answer 2

Correct Answers:

Raise the height of the client's bed.

Rationale :

🪑 The first action the nurse should take when preparing to reposition a client is to raise the height of the bed to a comfortable working level.

🪑 This reduces the need for bending or overreaching, which helps prevent back strain and musculoskeletal injuries.

🪑 Once the bed is at the proper height, the nurse can then focus on body mechanics, such as tightening abdominal muscles, aligning feet, and pivoting.

🪑 Safe patient handling begins with proper positioning of the caregiver, and bed height adjustment is a critical step in this process.

🪑 This step ensures ergonomic alignment and promotes safe, efficient movement of the client with minimal physical stress.

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Answer 3

Correct Answers:

Disease prevention.

Rationale :

🛡️ The nurse is demonstrating disease prevention by performing a blood pressure screening for a client with a known risk factor—a family history of hypertension.

🛡️ Disease prevention involves early detection and intervention to reduce the risk or progression of disease before symptoms appear.

🛡️ This action aligns with secondary prevention, which aims to identify and address health problems early through screenings and risk assessments.

🛡️ While health promotion and education are also important, the primary focus here is preventing the onset or progression of a specific condition—hypertension.

🛡️ Holistic health refers more broadly to addressing the emotional, spiritual, and physical well-being, rather than targeted clinical screenings

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Answer 4

Correct Answers:

Sensorimotor.

Rationale :

🧸 Object permanence—the understanding that objects continue to exist even when they cannot be seen—is a key developmental milestone that emerges during the sensorimotor stage.

🧸 The sensorimotor stage occurs from birth to about 2 years of age, where infants explore the world primarily through sensory experiences and motor activities.

🧸 Object permanence typically begins to develop around 8 to 12 months, marking a significant step in cognitive awareness and memory.

🧸 This concept lays the foundation for more complex reasoning and problem-solving in later stages.

🧸 Other stages (preoperational, concrete, and formal operational) build on these foundational concepts but do not introduce object permanence.

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Answer 5

Correct Answers:

"Seeing spots is a manifestation of diabetic retinopathy.”.

Rationale :

👁️ Diabetic retinopathy is a microvascular complication of diabetes that causes damage to the blood vessels of the retina, leading to leakage, swelling, and retinal ischemia.

👁️ One of the common early signs includes seeing spots or floaters, which occur due to bleeding or fluid leakage into the visual field.

👁️ If left untreated, it can progress to vision loss or blindness, making early recognition and treatment crucial.

👁️ Other choices like clouding of the lens (cataracts) and increased intraocular pressure (glaucoma) are unrelated to diabetic retinopathy.

👁️ Clients with diabetes should have a dilated eye exam annually, not every 2 years.

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Answer 6

Correct Answers:

Spirituality can increase the quality of life.

Rationale :

🕊️ Spirituality plays a significant role in helping clients near the end of life find meaning, comfort, and peace, which contributes to an improved quality of life.

🕊️ Many clients use spiritual beliefs or practices to cope with illness, suffering, and fear of death, enhancing emotional well-being.

🕊️ Supportive spiritual care can reduce anxiety, depression, and existential distress, promoting a sense of connection and dignity.

🕊️ Nurses play a key role in assessing spiritual needs and facilitating resources such as chaplain services or honoring cultural and religious rituals.

🕊️ Including spirituality in holistic care enhances end-of-life experiences for both clients and their families.

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Answer 7

Correct Answers:

Surgical incision.

Rationale :

💉 Acute pain is sudden in onset, usually related to tissue injury, and is short-term, often resolving as healing occurs.

💉 A surgical incision causes acute pain because it results from a specific injury (surgery) and typically improves as the incision heals.

💉 Acute pain serves a protective function, alerting the body to damage and promoting rest and recovery.

💉 Other options like fibromyalgia, peripheral neuropathy, and rheumatoid arthritis are examples of chronic pain conditions, which are long-lasting, often persisting for more than 3 months.

💉 Proper assessment and management of acute pain help prevent complications such as chronic pain development or delayed recovery.

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Answer 8

Correct Answers:

Dry between folds in the client's skin.

Rationale :

🧼 For clients who are incontinent, maintaining skin integrity is a priority to prevent moisture-associated skin damage and pressure injuries.

🧼 Thoroughly drying between skin folds after cleaning helps reduce moisture retention, friction, and microbial growth, which can lead to skin breakdown.

🧼 The nurse should use lukewarm water and a gentle cleanser—not hot water, which can strip protective oils and cause irritation.

🧼 Baby powder is discouraged because it can cake in moist areas and promote yeast infections.

🧼 Fluid restriction is not an appropriate strategy for managing incontinence and may lead to dehydration and urinary tract infections.

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Answer 9

Correct Answers:

Quality.

Rationale :

🔶 The "Q" in the PQRST pain assessment mnemonic stands for "Quality", which refers to how the pain feels in the client's own words (e.g., sharp, dull, burning, cramping).

🔶 Asking, “Can you describe what the pain feels like?” helps the nurse gather subjective data critical for pain evaluation and diagnosis.

🔶 The other components are:

P – Provocation/Precipitating factors (what causes or worsens it)

R – Region/Radiation (location and spread of pain)

S – Severity (intensity, often using a scale)

T – Timing (onset, duration, frequency)

🔶 Using the full PQRST model helps guide comprehensive pain assessment and management.

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Answer 10

Correct Answers:

Increase the client's fluid intake.

Rationale :

💧 Increasing fluid intake is a primary nonpharmacologic intervention for managing constipation, especially in clients on bedrest, who are at higher risk due to decreased mobility.

💧 Adequate hydration helps soften the stool, making it easier to pass and promoting regular bowel movements.

💧 Fluids, especially warm fluids, stimulate peristalsis more effectively than cold ones.

💧 Mineral oil is rarely used due to risks like aspiration and interference with fat-soluble vitamin absorption.

💧 A high-fiber diet, not low-fiber, is recommended to increase stool bulk and stimulate bowel activity.

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QLexNursing

1 :
A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

2 :
A nurse is preparing to reposition a client. Which of the following actions should the nurse take first?

3 :
A nurse is performing a blood pressure screening for a client who has a family history of hypertension. Which of the following concepts is the nurse demonstrating?

4 :
A nurse is teaching a class about Piaget's stages of cognitive development. The nurse should instruct that object permanence develops during which of the following stages?

5 :
A nurse is teaching a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the client?

6 :
A nurse is teaching a class about spirituality in clients who are near the end of life. Which of the following information should the nurse include?

7 :
A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of acute pain?

8 :
A nurse is caring for a client who is incontinent. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?

10 :
A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

QLexNursing

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

2 : A nurse is preparing to reposition a client. Which of the following actions should the nurse take first?

3 : A nurse is performing a blood pressure screening for a client who has a family history of hypertension. Which of the following concepts is the nurse demonstrating?

4 : A nurse is teaching a class about Piaget's stages of cognitive development. The nurse should instruct that object permanence develops during which of the following stages?

5 : A nurse is teaching a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the client?

6 : A nurse is teaching a class about spirituality in clients who are near the end of life. Which of the following information should the nurse include?

7 : A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of acute pain?

8 : A nurse is caring for a client who is incontinent. Which of the following actions should the nurse take?

9 : A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?

10 : A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

1 :
A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

2 :
A nurse is preparing to reposition a client. Which of the following actions should the nurse take first?

3 :
A nurse is performing a blood pressure screening for a client who has a family history of hypertension. Which of the following concepts is the nurse demonstrating?

4 :
A nurse is teaching a class about Piaget's stages of cognitive development. The nurse should instruct that object permanence develops during which of the following stages?

5 :
A nurse is teaching a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the client?

6 :
A nurse is teaching a class about spirituality in clients who are near the end of life. Which of the following information should the nurse include?

7 :
A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of acute pain?

8 :
A nurse is caring for a client who is incontinent. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?

10 :
A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?