A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?

Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

A client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by claiming the night shift nurse is aloof and expresses joy to see that, "My favorite nurse is on duty now." Which response is best for the nurse to provide to this client's dichotomous tendency?

Click to highlight the findings that would indicate the client is progressing as expected.

The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric

A client undergoes an above-the-knee amputation (AKA) of the right leg because of peripheral vascular disease. On the second postoperative day, the nurse enters the room to take the client's vital signs and finds the client lying in a prone position. The client asks for assistance in turning. Which action should the nurse take first?

The nurse is teaching a client's family member about seizure precautions. Which action described by the family member indicates the need for additional teaching?

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

The mental health nurse is leading a group about relaxation and explains the benefits of deep breathing for relaxation. As a female client begins to explain how she uses yoga to relax, another client interrupts and asks, "What's yoga?" Which is the nurse's best response?

The nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?