The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

An adult client presents to the community mental health center accompanied by the client’s spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last-minute decisions to take trips, sleeps only 2 to 4 hours a night, and has lost 33 pounds (15 kg) in the last 2 months. Which nursing problem has the greatest nursing priority?

During a one-to-one session with the nurse, a female client admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don’t remember, but my mother ran my father off when I was five.” The nurse should recognize that the client may be using which defense mechanism?

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client’s rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Which individual should the nurse consider at the highest risk for suicide?

A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

When a male client is asked about his reason for coming to the mental health clinic, he replies, “It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn’t want to do anything. It has been a really difficult time for me.” Which response should the nurse provide?