A nurse is caring for an older adult client.

Exhibits

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not.. I found the title to the car today, signed over to me.
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom. Client reports not wanting to eat anymore. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?

The nurse is continuing to care for the client.

Complete the following sentence by using the list of options.

The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition.

The action the nurse should take first is

A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

A nurse is caring for a 9-year-old child at a clinic.

After reviewing the discharge instructions with the family, which of the following statements by a parent indicate an understanding of the teaching? For each statement by the parent, click to specify if the statement reflects an understanding or indicates a need for reinforcement of the discharge teaching.

A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?

A nurse is caring for a neonate in the neonatal intensive care unit.

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Nurses' Notes

1200:

The neonate is 3 days old. Lung sounds clear to auscultation. Frequent episodes of apnea, responds to tactile stimuli. Oxygen saturation 95% to 98% via nasal cannula. Neonate on radiant warmer.

Temperature 36.3° C (97.3° F)

Heart rate 158/min

Respiratory rate 70/min

Substernal retractions and nasal flaring noted. Orogastric (OG) tube placement verified. Continuous breast milk feedings via OG tube initiated 12 hr ago. The umbilical arterial catheter (UAC) site is clean, dry, and intact. Peripheral pulses 2+. Capillary refill brisk. Abdomen is soft, bowel sounds are present. Abdominal circumference increased by 1 cm (0.4 in) since the prior assessment.

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery. Which of the following actions should the nurse take to promote learning?

A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on my chest." The client is weak and unable to walk. After the nurse initiates chest pain protocol, which of the following is the priority diagnostic test?