A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.

Patient Data

The nurse determines the plan of care.

For each action, click to indicate whether they would be included or not included in the plan of care for the client.

Each row must have only one response option selected.

Actions

Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse.

The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with:

• Fatigue
• Generalized weakness
• Muscle cramps
• Tingling sensation in her arms and legs
• Lightheadedness

She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.

Initial Vital Signs:

• Blood Pressure: 146/82 mmHg
• Heart Rate: 114 bpm
• Respiratory Rate: 18 bpm
• SpO₂: 98% on room air
• Temperature: 98.2 °F (36.8 °C) orally

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?

An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

For each client statement, select the statement(s) below that require follow-up teaching by the nurse.

"This diagnosis means that I am crazy."

"I can learn to manage my thoughts better through therapy."

"I can use holistic approaches like meditation to help my symptoms."

"Many people have the same response to a stressful situation as I am having right"

"I am at high risk for post-traumatic-stress disorder because I have acute stress disorder"

"I will probably need to be on medication for the rest of my life."