A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

During a one-to-one session with the nurse, a female client admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don’t remember, but my mother ran my father off when I was five.” The nurse should recognize that the client may be using which defense mechanism?

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?

A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant amitriptyline that he uses to help him sleep. After reviewing the assessment findings with the healthcare provider, a serum creatinine is obtained. Which information supports the reason for this laboratory test?