The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent.
What other assessment items are included in the primary survey? Select all that apply.

An adult client is admitted to the psychiatric unit due to a daily, intricate handwashing ritual that lasts two hours or more.

The client is concerned about maintaining cleanliness and refuses to sit on any chairs in the day area.

This client’s handwashing is indicative of what type of clinical behavior?

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes.
Which behaviors should the nurse prioritize for monitoring?

An elderly male patient, who has been experiencing abdominal pain, is admitted to the hospital from a long-term care facility.

It has been a week since his last bowel movement, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis.

In what order should the nurse implement the following interventions? Arrange from the highest priority at the top to the lowest at the bottom.

A client who follows Mormon beliefs is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply.

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours.
Which additional action should the nurse instruct the UAP to take each time the client is turned?

The primary caregiver of an elderly patient contacts the nurse at the outpatient clinic due to a sudden change in the patient’s behavior.

The caregiver informs the nurse that the patient, who is usually oriented and able to answer Questions, is now confused and agitated.

What actions should the nurse take? (Select all that apply)

A patient with acute renal failure (ARF) is admitted due to uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale.
What is the most important intervention for the nurse to include in this patient’s plan of care?

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

A client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness.

The client has been taking spironolactone 50 mg tablets PO every day.

The nurse receives a report from the lab that the client has a serum potassium level of 6.2 mEq/L (6.2 mmol/L). Which intervention is most important for the nurse to implement?