A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the client on use of call light.

Apply an ambulation alarm to the client’s leg.

Apply restraints to the client PRN.

Raise the four side rails of the client’s bed.

Check on the client hourly

Answer and Explanation

Correct Answer : A,B,D,E

A.   Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B.   Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.

C.   Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D.   Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.

E. Checking on the client hourly is an essential intervention to monitor the client’s mental status and ensure safety. Frequent assessments allow for early identification of complications related to opioid use, such as respiratory depression or increased sedation.

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Correct Answer is C

Explanation

A. Vomiting is not a specific manifestation of sepsis.
B. Hypertension is not a typical finding in sepsis; hypotension is more common.
C. Altered mental status, such as confusion or lethargy, can be a sign of sepsis- induced organ dysfunction.
D. While an elevated white blood cell (WBC) count is often seen in infection, it alone does not indicate sepsis. The key in sepsis is the body's dysregulated response to infection leading to organ dysfunction.

A. FACES B. Oucher C. Visual Analog Scale D. FLACC

Correct Answer is D

Explanation

A. The FACES scale is typically used with older children who can express their pain using facial expressions.
B. The Oucher scale is a self-report scale that relies on the child's ability to match their pain level to a set of standardized photographs.
C. The Visual Analog Scale is used with older children and adults but is not appropriate for infants.
D. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is specifically designed for infants and nonverbal children, taking into account their facial expressions, leg movement, activity level, cry, and consolability.

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A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?

Correct Answer is C

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A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infant’s pain level?

Correct Answer is D

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