A nursing student is looking at a telemetry screen with multiple rhythms. The unit is a step-down cardiac unit with delicate patients. Patients on Census. The unit has:

1. 84-year-old male with AFib, diaphoretic, and complaining of fatigue.

2. 45-year-old female with SVT not responding to adenosine.

3. 78-year-old female with bradycardia who was given atropine and epinephrine, yet unresolved.

4. 80-year-old male in pulseless Ventricular fibrillation being coded and transferred to Intensive Care Unit.

5. 69-year-old female who arrived at the unit symptomatic and currently being coded is pulseless with Ventricular Tachycardia.

The nurse on the step-down unit explains to the nursing student the electricity to be used for each dysrhythmia. Select the correct electricity to be used to manage the dysrhythmias listed:

Transcutaneous Pacing, Defibrillation, or Synchronized cardioversion?

Dysrhythmias:

1. Ventricular fibrillation.

2. PVC-run ventricular tachycardia with a pulse.

3. Atrial Flutter.

4. Bradycardia.

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder.

Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who has bipolar disorder and is taking lithium.

The client reports blurred vision and ataxia.

Which of the following actions should the nurse take?

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations.

Which of the following hallucinations is the priority for the nurse to address?

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity.

Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns.

Which of the following is the priority nursing intervention for this client?

A nurse is caring for a client who is experiencing suicidal thoughts.

Which of the following actions should the nurse take?.

A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?

A nurse is caring for a client who has bipolar disorder and a new prescription for valproate.

Which of the following instructions should the nurse give the client about the use of this medication?

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations.

Which of the following responses should the nurse make first?

A nurse in a mental health facility is caring for a client.

Medical History: Antisocial personality disorder.

Substance use disorder.

Nurses' Notes:. 1400: Client admitted to facility by court order for evaluation following arrest for disorderly conduct and resisting arrest.

Client states, "That judge is so stupid.

I don't belong here!" Client has rigid posture, is pacing around the room attempting to intimidate staff and other clients on the unit.

Extra staff members gather.

1500: Client escorted to room.

Client becomes flirtatious with assistant personnel (AP). Client introduced to roommate, whom they ignore.

Continues to flirt with AP. 1800: Client refuses to go to dining room for dinner.

States, "I'm not sitting down with a bunch of nuts.

Bring my food to me!". For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.