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Which of the following are true statements about a dispute between a business and its customer? Select all that apply.

39. Which actions by a nurse are most appropriate when caring for a hospice patient? (Select all that apply.)

18. A client receiving risperidone reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The client is diaphoretic. What is the nurse’s best analysis and action?

31. An older adult client was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this client. Which communication strategy will be most helpful?

3. The nurse is caring for a patient with an intracranial pressure ICP of 18 mm Hg and a GCS score of 9. Two hours following the administration of mannitol, which assessment finding by the nurse requires further action? Normal adult ICP: ~ 5–15 mm Hg Elevated ICP: > 20 mm Hg Intervention threshold: > 22 mm Hg (sustained) Central Venous Pressures CVP 2 to 6 mmHg   18 mm Hg → monitor closely 22 mm Hg → at the edge 23–25 mm Hg for several minutes → INTERVENE Nursing “At‑a‑Glance” MAP & ICP Goals Parameter Target MAP (ICP unknown) ≥ 80 mm Hg CPP goal 60–70 mm Hg ICP intervention threshold > 22 mm Hg  (5-15) ABGs Paco2 35–45 mm Hg

23. A client says, “Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist.” What is the nurse’s best initial action?

4. The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury?

14. A nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a salute. The client remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?

13.A client’s care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the client may be hallucinating?

8. The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action?