Correct Answer: B

Rationale: Full-thickness tissue loss with visible muscle is characteristic of a stage 3 or 4 pressure ulcer, indicating severe tissue damage common in advanced pressure ulcers.
Choice A is incorrect because erythema and intact skin describe a stage 1 pressure ulcer, not a fully developed one.
Choice C is incorrect because blanchable redness over a bony prominence indicates tissue at risk but not yet a pressure ulcer.
Choice D is incorrect because eschar may be present in unstageable pressure ulcers, but full-thickness loss with visible muscle is a more specific finding for stage 3 or 4.

Correct Answer: C

Rationale: Discussing with the client his inappropriate behavior prior to seclusion is important, but it's not the most appropriate action. The priority is to ensure the safety of the client and others, which can be achieved by documenting the client's behavior prior to seclusion. Offering fluids every 2 hours is a good practice to keep the client hydrated, especially if they are agitated or physically active. However, this is not the most appropriate action in this context. Documenting the client's behavior prior to being placed in seclusion is the most appropriate action. This documentation is crucial for legal and ethical reasons, and it helps in evaluating the effectiveness of the intervention. Assessing the client's behavior once every hour is important to monitor the client's condition and response to seclusion. However, this is not the most appropriate action in this context.

Correct Answer: C

Rationale: Expecting a metallic taste in the mouth is a common side effect of metronidazole, and informing the client helps them anticipate and tolerate this effect during treatment for bacterial vaginosis.
Choice A is correct but not the best answer here, as avoiding alcohol is critical to prevent a disulfiram-like reaction, but the question focuses on expected effects, making C more specific.
Choice B is incorrect because metronidazole can be taken with or without food; a high-fat meal is not necessary.
Choice D is incorrect because metronidazole is typically taken 2-3 times daily, not only at bedtime, to maintain therapeutic levels.

Correct Answer: A

Rationale: Documenting the client's condition every 15 minutes is a crucial part of using restraints. Regular documentation helps ensure the safety and well-being of the client, as it allows for continuous monitoring and timely intervention if necessary. Requesting a PRN (as needed) restraint prescription for clients who are aggressive is not a recommended practice. Restraints should only be used as a last resort and must be based on a thorough assessment of the client's condition, not solely on their behavior. Attaching the restraint to the bed's side rails is not recommended. This can increase the risk of injury to the client. Restraints should be attached to a part of the bed frame that moves with the client, such as the head or footboard. While it's important to regularly check and adjust restraints for comfort and safety, there's no specific guideline that restraints should be removed every 4 hours. The frequency of removal and repositioning will depend on the individual client's condition and needs.

Correct Answer: A

Rationale: Avoiding driving is critical with lorazepam due to sedation. Grapefruit juice is unrelated, weight changes are not typical, and stopping abruptly risks withdrawal.