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An elderly client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client’s safety while walking in the halls, what should the nurse do?

A new antenatal G6, T4, P0, A1, L4 client attends her first prenatal visit with her partner. The nurse is assessing this couple’s psychological response to the pregnancy. Which finding requires the most immediate follow-up?

In which maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks’ gestation is in the left occipitoanterior (LOA) position?

The nurse is applying a hand mitt restraint for a client with pruritus (see figure). The nurse should first:

A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, what would be the most appropriate outcome for the couple to accomplish by the end of this visit?  

A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is admitted to the subacute unit after reporting feeling empty and lonely, being unable to sleep, and eating very little for the last week. Her arms are scarred from frequent selfmutilation. What should the nurse do in order of priority from first to last?  Monitor for suicide and self-mutilation. Discuss the issues of loneliness and emptiness. Monitor sleeping and eating behaviors. Discuss her housing options for after discharge.

The nurse recognizes the client in the emergency department from a picture in the local paper. The client has recently received a major scholarship for high academic achievement. The client tells the nurse that he hears voices that tell him he is worthless. He has tried to kill himself. What statement is the most appropriate for the nurse to use first when attempting to establish a therapeutic relationship?

At 0800, the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:

The nurse is caring for a G2, T1, P0, A0, L1 client at term. The client is completely effaced, dilated to 2 cm, with contractions every 3 minutes lasting 45 seconds. The client is asking for an epidural to make her more comfortable. Indicate the appropriate response by the nurse.

On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client’s blood pressure is 70/50 mm Hg, and her pulse rate is 120 bpm. The nurse notifies the primary healthcare provider (HCP) immediately because of the possibility of: