A nurse in a mental health facility is collecting a blood specimen from a client.
The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries.
My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?.

A nurse is assisting with the care of a client who has dementia.
Which of the following actions should the nurse take?.

A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary.
For which of the following interventions should the nurse confirm that the client has given informed consent?.

A nurse is caring for multiple clients on a mental health unit.
Which of the following clients should the nurse attend to first?.

A client is becoming increasingly agitated, anxious, and tense.
The nurse notes a clenched jaw and a change in the pitch of the client's voice.
Which of the following interventions should the nurse implement first?.

A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency.
The nurse should encourage the client to participate in which of the following groups? .

A nurse is caring for a group of clients in a pediatric clinic.
Which of the following clients is at the highest risk for physical abuse? .

A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia.
Which of the following statements by the client indicates an understanding of the teaching?.

A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder.
Which of the following statements by the parent indicates an understanding of the redirection technique? .

A nurse is assisting in the care of a client in the emergency department (ED). Nurses' Notes 0205: Client brought to the ED by police after being found wandering on the street.

Client able to provide identity to police but not able to identify place or time.

Family notified.

Client confused and agitated.

Appearance is disheveled.

Mucous membranes dry.

Lungs clear and equal, heart rhythm regular.

During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.

Vital Signs 0200: Temperature 38.6°C (101.5°F), Heart rate 104/min, Respiratory rate 18/min, Blood pressure 158/96 mm Hg, Oxygen saturation 98% on room air.

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