A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

A nurse is supervising an assistive personnel (AP. who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?

A home health nurse is caring for a client who has Alzheimer's disease. The client's son is concerned about his mother becoming frustrated. Which of the following interventions should the nurse include?

A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility.

Nurses' Notes 1500:

The client is restless and is not following commands. The client does not tolerate lying flat. Skin warm and dry. Regular heart sounds without murmur. Respirations labored. Breath sounds with the right-sidedcrackles and wheezes in the posterior lower lobe. Abdomen soft, nondistended with positive bowel sounds in all four quadrants. Tremors in hands.

Admission Assessment 1400:

The client's history includes cigarette smoking for 50 years but quit 3 years ago, Parkinson's disease, and anxiety. Yesterday, the client reported "feeling bad." The client is alert and oriented to self, reports upper chest discomfort, and is coughing up thick clear sputum.

Select the 3 findings that require immediate follow-up.

Nurses' Notes Preoperative 0730:

The client is scheduled for a left stapedectomy.

Pupils 3.5 mm, equal, round, and reactive to light. Smile symmetrical.

Mucous membranes show color expected for the client's skin tone and moisture.

Speech clear.

Skin warm and dry. Lungs clear bilaterally.

Apical heart rate regular at 78/min. Postoperative

1230:

Pupils were 3 mm, equal, and reactive to light.

Smile asymmetrical. Mucous membranes pink. Speech hoarse.

Client with left facial droop Skin warm and dry.

The client reports vertigo and nausea.

Bilateral breath sounds clear and present throughout. Apical heart rate regular at 92/min.

The client reports left ear discomfort and rates the pain as 5 on a scale of 0 to 10. The client states that her hearing has diminished following surgery.

Which of the following findings requires further action by the nurse? Select all that apply.