A nurse is caring for an adolescent who was recently sexually assaulted.
Which of the following statements by the adolescent's guardian represents the presence of a positive support system? .

A nurse is caring for an adolescent who was recently sexually assaulted.
Which of the following statements by the adolescent's guardian represents the presence of a positive support system? .

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.

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide.
Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.) .

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 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 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 client is becoming increasingly agitated, anxious, and tense.
The nurse notes a clenched jaw and a change in the pitch of the client's voice.
Which of the following interventions should the nurse implement first?.

A nurse is caring for a client who has an opioid use disorder.
The nurse should anticipate that the provider will prescribe which of the following medications for treatment?.

A nurse is collecting data for a health history from a client who has antisocial personality disorder.
Which of the following clinical findings is associated with this disorder?.

A nurse is caring for a client who has depression and reports only sleeping a few hours each night.
Which of the following instructions should the nurse give the client to promote sleep? .