The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.

For each client statement, click to highlight the statement(s) below that require follow up teaching by the nurse.

•  I am at high risk for post-traumatic-stress disorder because I have acute stress disorder
•  I can use holistic approaches like meditation to help my symptoms.
•  I can learn to manage my thoughts better through therapy.
• Many people have the same response to a stressful situation as I am having.
•  This diagnosis means that I am crazy.
•  I will probably need to be on medication for the rest of my life.

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

Six weeks after the birth of a child with Trisomy 21, the parents return to the prenatal clinic for a follow-up visit. They have spoken with a genetic counselor, but are still unsure about the risk of having another child with Trisomy 21. The couple brings literature from the counselor with them, and asks the nurse to explain it. Which action should the nurse take?

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which intervention should the nurse implement first?

The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action?

The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?