Question

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Answer 1

Correct Answers:

Maintaining a patent airway

Rationale :

🔵 Airway patency is the top priority in an unconscious client because without oxygen delivery, brain injury and death can occur within minutes.

🔵 The unconscious state increases the risk for airway obstruction from the tongue, secretions, or aspiration.

🔵 ABC principles (Airway, Breathing, Circulation) dictate that airway comes before all other interventions.

🔵 Proper airway maintenance supports oxygenation and ventilation, preventing hypoxia and respiratory arrest.

🔵 All other interventions (I&O, NG tube, pain control) are secondary to ensuring the client can breathe.

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Answer 2

Correct Answers:

Posttraumatic stress disorder

Rationale :

🟢 PTSD develops after exposure to traumatic events, such as combat, leading to symptoms like nightmares, flashbacks, and hyperarousal.

🟢 The soldier’s timeline (2 weeks post-deployment) and re-experiencing symptoms match the diagnostic criteria for PTSD.

🟢 Sleep disturbances and avoidance behaviors are hallmark signs.

🟢 PTSD can significantly impair social and occupational functioning if untreated.

🟢 Early recognition allows for interventions like cognitive behavioral therapy and trauma-focused counseling.

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Answer 3

Correct Answers:

Tolerance

Rationale :

🟣 Tolerance occurs when a person needs larger amounts of a substance to achieve the same effect.

🟣 In alcohol tolerance, the body adapts to chronic use, leading to fewer observable effects at high blood alcohol levels.

🟣 The nervous system becomes less responsive to alcohol’s depressant effects.

🟣 This adaptation increases risk for dependence and withdrawal symptoms.

🟣 Tolerance is a key clinical sign in substance use disorders.

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Answer 4

Correct Answers:

Pinpoint-sized pupils

Rationale :

🟡 Miosis (pinpoint pupils) is a classic indicator of opioid use due to parasympathetic stimulation.

🟡 Opiates depress the central nervous system, affecting the brainstem’s control over the pupils.

🟡 This sign often accompanies respiratory depression and sedation.

🟡 Recognition of this finding can aid in early overdose detection.

🟡 Pinpoint pupils help differentiate opioid intoxication from other CNS depressants.

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Answer 5

Correct Answers:

Risk for aspiration

Rationale :

🔴 Absent gag reflex means the client cannot protect their airway during swallowing.

🔴 This greatly increases risk of aspiration pneumonia.

🔴 The vagus nerve (CN X) is essential for the swallow reflex and airway protection.

🔴 Aspiration can cause hypoxia, infection, and airway obstruction.

🔴 Swallowing safety interventions must be implemented immediately.

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Answer 6

Correct Answers:

Repetitive thoughts and recurring impulses

Rationale :

🟠 Obsessions are intrusive thoughts, and compulsions are repetitive behaviors aimed at reducing anxiety.

🟠 OCD causes significant distress and functional impairment.

🟠 The compulsions are often unrelated logically to the obsessions but serve as anxiety relief.

🟠 Early diagnosis and treatment prevent chronicity.

🟠 Cognitive-behavioral therapy and SSRIs are first-line treatments.

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Answer 7

Correct Answers:

drink adequate noncaffeinated and nonalcoholic beverages.

Rationale :

🟤 Xerostomia (dry mouth) can be relieved by frequent fluid intake.

🟤 Caffeine and alcohol worsen dryness by dehydrating oral tissues.

🟤 Adequate fluids improve oral comfort and swallowing.

🟤 Encouraging hydration prevents dental caries and infections.

🟤 Saliva substitutes may also be used in chronic cases.

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Answer 8

Correct Answers:

Cognitive Behavioral Therapy

Rationale :

🔷 CBT targets irrational thoughts and replaces them with realistic beliefs.

🔷 It is effective for anxiety, depression, and phobias.

🔷 The therapy is structured, goal-oriented, and time-limited.

🔷 Clients learn to identify cognitive distortions.

🔷 Skills from CBT are useful for long-term relapse prevention.

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Answer 9

Correct Answers:

respiratory depression.

Rationale :

🟩 Heroin overdose depresses the brainstem’s respiratory centers.

🟩 This leads to hypoventilation and hypoxia, which are life-threatening.

🟩 Immediate intervention with naloxone can reverse effects.

🟩 Airway and breathing support are critical priorities.

🟩 Untreated, this can result in respiratory arrest and death.

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Answer 10

Correct Answers:

Tremors, headache, flushed face, and hallucinations

Rationale :

🟥 Alcohol withdrawal symptoms appear within hours and peak in 24–72 hours.

🟥 Tremors, hallucinations, and autonomic hyperactivity are common.

🟥 Without treatment, progression to delirium tremens can occur.

🟥 Monitoring and benzodiazepine therapy are crucial.

🟥 Early detection prevents seizures and severe complications.

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Med surg exam( river valley college)

No.

1 :
The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

2 :
A soldier has been back from Iraq for two weeks. He is being seen in the outpatient mental health clinic due to complaints of inability to sleep, nightmares, and flashbacks. The nurse would expect the client to be diagnosed with which of the following?

3 :
A client has a blood alcohol level that is double the legal limit for driving yet does not exhibit behaviors of intoxication. The nurse knows that this is due to which effect?

4 :
Which of the following assessment findings is observed in a client with opiate use?

5 :
A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

6 :
A client is admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive symptoms. Obsessive- compulsive disorder (OCD) is associated with:

7 :
A nurse is caring for a client with complaints of xerostomia. The nurse should encourage the client to?

8 :
Which type of therapy assists the clients to alter their irrational thinking?

9 :
Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is:

10 :
A 51-year-old male has been admitted to the detoxification unit with acute symptoms of alcohol withdrawal. Nursing assessment is likely to reveal what?

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Med surg exam( river valley college)

No.

1 : The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

2 : A soldier has been back from Iraq for two weeks. He is being seen in the outpatient mental health clinic due to complaints of inability to sleep, nightmares, and flashbacks. The nurse would expect the client to be diagnosed with which of the following?

3 : A client has a blood alcohol level that is double the legal limit for driving yet does not exhibit behaviors of intoxication. The nurse knows that this is due to which effect?

4 : Which of the following assessment findings is observed in a client with opiate use?

5 : A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

6 : A client is admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive symptoms. Obsessive- compulsive disorder (OCD) is associated with:

7 : A nurse is caring for a client with complaints of xerostomia. The nurse should encourage the client to?

8 : Which type of therapy assists the clients to alter their irrational thinking?

9 : Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is:

10 : A 51-year-old male has been admitted to the detoxification unit with acute symptoms of alcohol withdrawal. Nursing assessment is likely to reveal what?

1 :
The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

2 :
A soldier has been back from Iraq for two weeks. He is being seen in the outpatient mental health clinic due to complaints of inability to sleep, nightmares, and flashbacks. The nurse would expect the client to be diagnosed with which of the following?

3 :
A client has a blood alcohol level that is double the legal limit for driving yet does not exhibit behaviors of intoxication. The nurse knows that this is due to which effect?

4 :
Which of the following assessment findings is observed in a client with opiate use?

5 :
A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

6 :
A client is admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive symptoms. Obsessive- compulsive disorder (OCD) is associated with:

7 :
A nurse is caring for a client with complaints of xerostomia. The nurse should encourage the client to?

8 :
Which type of therapy assists the clients to alter their irrational thinking?

9 :
Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is:

10 :
A 51-year-old male has been admitted to the detoxification unit with acute symptoms of alcohol withdrawal. Nursing assessment is likely to reveal what?