Exhibits

For each client statement, select the statement(s) below that require follow-up teaching by the nurse.

 "This diagnosis means that I am crazy." 

 "I can learn to manage my thoughts better through therapy." 

 "I can use holistic approaches like meditation to help my symptoms." 

 "Many people have the same response to a stressful situation as I am having right” 

 "I am at high risk for post-traumatic-stress disorder because I have acute stress disorder” 

 "I will probably need to be on medication for the rest of my life." 

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking.

Which action should the nurse implement?

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

Patient Data

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

Click to specify which client statement or behavior 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 but may have more than one answer selected.

Patient Data

The client has been in IMU unit for 3 days and the physician plans to discharge her home today.

Select the client actions that were effective in her treatment.

Patient Data

The nurse determines the plan of care.

For each action, click to indicate whether they would be included or not included in the plan of care for the client.

Each row must have only one response option selected.

Actions

Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse.

The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with:

• Fatigue
• Generalized weakness
• Muscle cramps
• Tingling sensation in her arms and legs
• Lightheadedness

She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.

Initial Vital Signs:

• Blood Pressure: 146/82 mmHg
• Heart Rate: 114 bpm
• Respiratory Rate: 18 bpm
• SpO₂: 98% on room air
• Temperature: 98.2 °F (36.8 °C) orally

An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?