The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother’s care.

While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room.
What should be the nurse’s initial action?

The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

The nurse is educating a first-time pregnant woman about preeclampsia.
Which symptoms are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

A child with an Escherichia coli urinary tract infection is receiving a secondary infusion of gentamicin 60 mg every 8 hours IV, which is to be infused over 30 minutes.

The medication is delivered by the pharmacy diluted in a 50 ml bag of saline.

What should be the infusion pump’s regulation in mL/hour? (Provide the numeric value only.)

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy express that their child wants to continue attending swimming classes.
How should the nurse respond?

The nurse is collecting a heel-stick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid- stimulating hormone (TSH) levels, prior to discharging a 2-day-old patient.
When the parents ask why these tests are being conducted, which explanation should the nurse provide?

The nurse is caring for a client with a history of coronary artery disease who reports waking up with a sudden onset of vise-like chest pressure.

The client reports that the pain decreases at rest but continues to feel a constant mid-chest pressure. What intervention should the nurse perform in the immediate management of the client?

What intervention should the nurse perform in the immediate management of the client?

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness.

Following a paracentesis, the nurse receives laboratory results of the ascitic fluid that show the polymorphonuclear leukocyte count is 425/mm (0.42 x 10/L). After notifying the healthcare provider, what action should the nurse take next?

A 35-year-old woman, who works as a legal secretary, visits the outpatient clinic for an assessment of consistent pain in her hands.

She reports that the pain is identical in both hands and wrists but is worse upon waking. The pain and stiffness have persisted for the past 3 months.

She believes she has arthritis because her mother and grandmother both have arthritis.

Based on the data provided, determine the most likely condition the client is experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying.
What interventions should the nurse include in this client’s plan of care? Select all that apply.