Nurses' Notes

Client ate 80% of lunch with encouragement. Mild edema to hands, feet, and ankles. Client states, "It feels like my heart is jumping in my chest."

Graphic Results

BP 100/64 mm Hg

Pulse rate 58/min

Respiratory rate 16/min

Temperature 36.4° C (97.5° F)

SaO2 96%

BMI 16

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider?

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?

A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?

A nurse is caring for a client who has schizophrenia and is preparing for discharge. Nurses' Notes

Admission:

25-year-old client admitted with positive symptoms of schizophrenia. Client has a history of substance use, anxiety, and depression. Client demonstrates alterations in speech and persecutory delusions. Client states that they hear voices that are warning them of danger and that they should stay away from a coworker because the coworker is conspiring against them. Day 5-Discharge:

No delusions or hallucinations noted. Speech coherent. Client has a well-groomed appearance. Individual therapy attended daily.

Medication Administration Record Haloperidol 3 mg PO twice daily

The nurse is providing discharge teaching to the client. Which of the following information should the nurse include when educating the client about relapse prevention? Select all that apply.

A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?