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?

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy.

Which of the following information should the nurse not include in the change-of-shift report?

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

A nurse is planning to reinforce teaching with a preschooler who is about to undergo an incision and

drainage for cellulitis on the left arm. Which of the following techniques should the nurse use?

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding.

Which of the following actions should the nurse take?

A nurse is teaching a client who has a new prescription for metformin extended-release tablets.
Which of the following statements by the client indicates an understanding of the teaching?

A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle-feeding her newborn.
Which of the following instructions should the nurse include in the teaching?

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial selfinflicted lacerations on their forearms.

The nurse should identify these behaviors as characteristics of which of the following personality disorders?

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia.

Which of the following interventions should the nurse include in the plan?

A nurse is caring for an 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.

Select the 4 findings that require follow-up.