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.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

A nurse is collecting data from a client who has anorexia nervosa.
Which of the following findings should the nurse expect? (Select all that apply.) .

A nurse is collecting data from a client who has schizophrenia.
Which of the following client statements indicates that the client is experiencing a command hallucination? .

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.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

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

A nurse is caring for a client who has an anxiety disorder.
The client transforms their anxiety into physical manifestations.
The nurse should recognize that the client is ing which of the following manifestations?.

A nurse is collecting data from a client who is experiencing opioid withdrawal.
Which of the following manifestations should the nurse expect?.

A nurse is caring for a client who experienced a fall.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.

A nurse is collecting data from a client who has antisocial personality disorder.
Which of the following findings should the nurse expect? (Select all that apply.) .

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder.
Which of the following actions should the nurse take first? .

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.

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.

0230: 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.

The client's adult child arrived at the ED and went to the client's room.

The client identified the family member.

The client is pacing and agitated and states, "I don't understand why I am here.”. The adult child asks the nurse to talk outside of the room and states, "I don't know why they are so confused.

They are not normally like this.”. The adult child.

Which of the following interventions should the nurse include in the client's care? Select the 3 interventions the nurse should implement.

Approach client slowly.

Alternate nursing staff daily.

Maintain a low stimulation environment.

Reorient client to person, place, and time frequently.

Provide the client with limited information about the diagnosis.