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 self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?

A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism?

A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?

A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority to consult?

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?

The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take?

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?

A nurse is teaching a client about condom use. Which of the following client statements should the nurse identify as an understanding of the teaching?

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?

A nurse is caring for a client who is pregnant.

Exhibit 1

Nurses' Notes

1000:

The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.

1015:

IV fluids initiated. Prochlorperazine administered via intermittent IV bolus.

1100:

Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine.

1500:

Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine.

Exhibit 2

Vital Signs

1000:

Temperature 36.8° C(98.2° F)

Heart rate 112/min

Respiratory rate 20/min

Blood pressure 100/65 mm Hg

SaO 97% on room air

1200:

Temperature 37° C(98.6° F)

Heart rate 102/min

Respiratory rate 20/min

Blood pressure 104/70 mm Hg

SaO2 98% on room air

1500:

Temperature 36.8° C(98.2° F)

Heart rate 90/min

Respiratory rate 18/min

Blood pressure 110/72 mm Hg

SaO2 97% on room air

For each discharge instruction, specify if each action is recommended or contraindicated for the client.