A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?

A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?

A nurse is assessing a client who has a history of substance use disorder and states, "People are out to get me." The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?

A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify as acting in the role of monopolizer?

A nurse is caring for a client who has schizophrenia and is preparing for discharge. Nurses' Notes

Admission:

25-year-old client admitted with positive symptoms of schizophrenia. Client has a history of substance use, anxiety, and depression. Client demonstrates alterations in speech and persecutory delusions. Client states that they hear voices that are warning them of danger and that they should stay away from a coworker because the coworker is conspiring against them. Day 5-Discharge:

No delusions or hallucinations noted. Speech coherent. Client has a well-groomed appearance. Individual therapy attended daily.

Medication Administration Record Haloperidol 3 mg PO twice daily

The nurse is providing discharge teaching to the client. Which of the following information should the nurse include when educating the client about relapse prevention? Select all that apply.

Nurses' Notes

Client ate 80% of lunch with encouragement. Mild edema to hands, feet, and ankles. Client states, "It feels like my heart is jumping in my chest."

Graphic Results

BP 100/64 mm Hg

Pulse rate 58/min

Respiratory rate 16/min

Temperature 36.4° C (97.5° F)

SaO2 96%

BMI 16

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider?

What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?

A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "I feel unmotivated and don't feel like leaving my home." Which of the following recommendations should the nurse make to address the client's social isolation?