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

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 assisting with reminiscence therapy for a group of older adult clients.
Which of the following strategies should the nurse implement? .

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.

A nurse is contributing to the plan of care for a client who has acute delirium.
Which of the following interventions should the nurse include in the plan of care? .

A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication.
The client has prescriptions for an anxiolytic and an SSRI antidepressant.
Which of the following precautions should the nurse take?.

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.

A nurse is speaking with the sibling of a client who refuses to see visitors.
Which of the following actions should the nurse take?.

A nurse is assisting with teaching a group of older adult clients about behavioral expectations.
Which of the following actions should the nurse take to help eliminate barriers to learning?.