A nurse is caring for a client who has a new diagnosis of cancer.
The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?.

A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary.
For which of the following interventions should the nurse confirm that the client has given informed consent?.

A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium.
To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication? .

A nurse is collecting data from a client who is experiencing opioid withdrawal.
Which of the following manifestations should the nurse expect?.

A nurse is collecting data from a client who has antisocial personality disorder.
Which of the following findings should the nurse expect? (Select all that apply.) .

A nurse is collecting data from a client who experienced physical abuse as a child.
Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?.

A nurse is assisting with teaching a group of older adult clients about behavioral expectations.
Which of the following actions should the nurse take to help eliminate barriers to learning?.

A nurse is contributing to the plan of care for a client who has acute delirium.
Which of the following interventions should the nurse include in the plan of care? .

A nurse in a mental health facility is collecting a blood specimen from a client.
The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

A nurse is assisting with reminiscence therapy for a group of older adult clients.
Which of the following strategies should the nurse implement? .

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.

Nurses' Notes 0205: Client brought to the ED by police after being found wandering on the street.

Client able to provide identity to police but not able to identify place or time.

Family notified.

0230: Client confused and agitated.

Appearance is disheveled.

Mucous membranes dry.

Lungs clear and equal, heart rhythm regular.

During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.

The client's adult child arrived at the ED and went to the client's room.

The client identified the family member.

The client is pacing and agitated and states, "I don't understand why I am here.”. The adult child asks the nurse to talk outside of the room and states, "I don't know why they are so confused.

They are not normally like this.”. The adult child.

Which of the following interventions should the nurse include in the client's care? Select the 3 interventions the nurse should implement.

Approach client slowly.

Alternate nursing staff daily.

Maintain a low stimulation environment.

Reorient client to person, place, and time frequently.

Provide the client with limited information about the diagnosis.