Exhibits

The nurse engages the client in conversation about her feelings and some of her coping mechanisms.

Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and fie me up." Which approach should the nurse use with the client?

An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks how to know that the spouse's death is imminent because their two adult children want to be there when the client dies. Which is the best response by the nurse?

Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to address

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

A client is admitted with bipolar disorder, manic psychosis. The client is placed in seclusion after unsuccessful attempts by staff at deescalating the client during a sudden mood swing from laughter to jumping and screaming threats while waving a plastic dinner knife. The client is given haloperidol 5 mg IM STAT prior to seclusion. Which intervention is most important for the nurse to implement immediately after seclusion?

A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 88 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?

Reference Range:

Arterial Blood Gas (ABG)

pH Adult/child: 7.35 to 7.45]

PaCO2 [Adult/child: 35 to 45 mm Hg]

HCO-[Adult/child: 21 to 28 mEq/L (21 to 28 mmol/L)]

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed.

Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.