A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?

The nurse is assisting in the care of the client who is at 30 weeks of gestation. Nurses' Notes

1200:

Provided a quiet environment, dimmed the lights, and encouraged client to remain in bed in the side-lying position.

Encouraged client to cough and take deep breaths regularly.

Assisted with insertion of 18-gauge IV and initiation of IV fluid.

Assisted with insertion of indwelling urinary catheter per provider prescription. Maintained strict 180.

FHR 136/min via external fetal monitor. Minimal variability noted, no contractions present.

1400:

Client is lethargic. Heart rate regular, respirations shallow DTR 1+ bilaterally.

Urine output 20 mL in the last hour

1405:

Assists with discontinuation of magnesium sulfate infusion Notifies provider of client status.

1800:

Client is alert and responsive. Heart rate regular respirations even and unlabored. DTR 2- bilaterally

Oxygen saturation (SaO) 95% on 2 L nasal cannula Respiratory rate 18/min

Select the findings that indicate the client's condition has improved.

A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?

A nurse is collecting data from a client who reports difficulty sleeping at night. Which of the following client statements indicates an understanding of sleep promotion?

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

A nurse is assessing a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse expect?

A nurse is reviewing the medical record of a client. These are the medical reports; Hypoactive bowel sounds upon auscultation, abdomen soft, not distended on palpation and urinary output of 130mL/4hr. Which of the following findings should the nurse report to the provider?

A nurse is reinforcing teaching with a new parent about bathing her newborn. Which of the following statements should the nurse include?