A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

The nurse is continuing to care for the adolescent.

Admission Assessment

1400:

Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.

Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Which of the following prescriptions should the nurse anticipate from the provider?

A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

A nurse on a mental health unit is caring for a client.

Nurses' Notes

Day 1, 1300:

Client admitted following a suicide attempt. Client's family reports client has not left bedroom in 1 week. Client previously. diagnosed with bipolar disorder.

Client reports feeling excessively tired and light-headed. Allergies: Client's family reports allergy to SSRIS (angioedema) and penicillin (anaphylaxis).

1600:

Client has been sleeping in their room since admission. Flat affect noted.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile idiopathic arthritis. Which of the following interventions should the nurse include in the teaching?

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?