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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A nurse is collecting data from a client who experienced physical abuse as a child.
Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?.

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

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family.
Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.

A nurse is caring for a client who has dementia and is experiencing an increased number of falls.
Which of the following actions should the nurse take?.

A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder.

Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.

Use a leading zero if it applies.

Do not use a trailing zero.).

A nurse is collecting data from an adult client in an outpatient mental health clinic.
The nurse should identify which of the following events as a potential cause of a maturational crisis?.

A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium.
To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication? .

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 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 client who has a new diagnosis of cancer.
The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?.