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The nurse is performing an admission assessment on a client admitted with a diagnosis of fever of unknown origin.  Which nursing action demonstrates competence under the Nurse Practice Act?

The nurse is performing a Mini Mental Status Examination (MMSE).  The nurse would assess for recall by asking the client which of the following questions?

The nurse is caring for a 6-year-old client who was brought to the primary healthcare provider’s office by their parents with complaints of severe abdominal pain. The parents reported that the pain has been present for around 4 hours and that the client has had 2 episodes of vomiting in the last 8 hours. The parents report the client’s temperature prior to arriving was 100.4 F.   Which of the following assessments does the nurse recognize should be completed first?     

Which of the following best describes the primary goal of evidence-based practice (EBP) in nursing?

After evaluating the meal tray of a Jewish client at 1300, the nurse notices that the client ate none of the meal. Which intervention should the nurse implement first?  

The nurse is caring for an adolescent client who was admitted to the unit for nutritional support related to their diagnosis of anorexia nervosa. The client is mildly dehydrated, has a potassium level of 3.4 mEq/L (reference range: 3.5-5.0 mEq/L), and has experienced weight loss of more than 25% of their body weight within the past 3 months. What does the nurse identify as the primary goal for this client?  

A nurse is continuing to care for the client on day 7. Nurses’ Notes Diagnostic Results Vital Signs  History and Physical Day 1, 1000: Client is an 18-year-old female, brought in by parent who reports client has not been eating well for several months and has lost 9 kg (20 lb). Client states, “I don’t want to eat because I will gain weight. I feel so fat.”  Client reports loss of appetite and admits to inducing vomiting after meals. Client is emaciated in appearance and has edema of the lower extremities and lanugo. Reports last menstrual period was 6 months ago.  Client is 160 cm (63 in) tall, and today’s weight is 40 kg (88 lb). BMI 15.6 Client is a senior in high school and is on the track team. Requests friends be allowed to come visit. Day 2, 0700: Client refuses to eat breakfast. Client has flat affect, wants to stay in bed and refuses to get dressed. Client states, “Everything is hopeless, I want it all to end.” 12 hour intake was 230 mL, output was 260 mL. Today’s weight is 39.5 kg (87 lb). Day 3, 0630: Today’s weight is 39.5 kg (87 lb).0830: Client consumed 20% of breakfast. Client has poor skin turgor and flat affect.Day 7, 0630: Weight 40.1 kg (88.5 lb)0830: Client consumed 50% of breakfast and 120 mL (4 oz) of liquid supplement.  Reports difficulty sleeping and frequent waking during the night. Requesting to go back to bed and sleep, flat affect noted with slow, quiet speech. Client refused to attend group and individual therapy sessions yesterday, spent most of the day in bed. Has not showered or changed clothes in two days. Day 1, 1030: Basic metabolic profile (BMP):Sodium 152 mEq/L (136 to 145 mEq/L)Potassium 3.1 mEq/L (3.5 to 5 mEq/L)Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL)Phosphate 2.8 mg/dL (3 to 4.5 mg/dL)Magnesium 1.1 mEq/L (1.3 to 2.1 mEq/L)Hgb 16 g/dL (12 to 16 g/dL)Hct 46% (37% to 47%)Day 1, 1030: ECG:  Brady dysrhythmia Day 2, 0630: BMP: Sodium 146 mEq/L (136 to 145 mEq/L)  Potassium 3.5 mEq/L (3.5 to 5 mEq/L)   Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL) Phosphate 2.9 mg/dL (3 to 4.5 mg/dL) Magnesium 1.3 mEq/L (1.3 to 2.1 mEq/L)   Day 3, 0830: BMP: Sodium 150 mEq/L (136 to 145 mEq/L)  Potassium 3.3 mEq/L (3.5 to 5 mEq/L)   Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL) Phosphate 2.8 mg/dL (3 to 4.5 mg/dL) Magnesium 1.1 mEq/L (1.3 to 2.1 mEq/L)Day 7, 0630: BMP: Sodium 145 mEq/L (136 to 145 mEq/L)  Potassium 3.5 mEq/L (3.5 to 5 mEq/L)   Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL) Phosphate 3.1 mg/dL (3 to 4.5 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Vital Signs Day 1, 1000:Temperature 35.5° C (95.9° F)Heart rate 50/minRespiratory rate 18/minBlood pressure 88/60 mm HgSaO2 94% on room air Day 2, 0700: Temperature 35.8° C (96.4° F) Heart rate 54/min Respiratory rate 16/min Blood pressure 84/52 mm Hg SaO2 96% on room air Day 3, 0830: Temperature 35.5° C (95.9° F) Heart rate 50/min Respiratory rate 16/min Blood pressure 90/64 mm Hg SaO2 95% on room airDay 7, 0830: Temperature 36.1° C (97° F) Heart rate 62/min Respiratory rate 18/min Blood pressure 92/60 mm Hg SaO2 96% on room air    History & Physical Day 1,1000: Tonsillectomy 13 years agoDenies use of alcohol and drugsNonsmoker The nurse is evaluating the client’s progress toward meeting treatment goals after one week of treatment. Which of the following findings indicates the client’s condition is improving? 

A psychiatric nurse working as a case manager in a community mental health center receives a call from the front desk that a visitor is asking for information about a client at the center.  Under what circumstances can the nurse release information to the visitor about the client?

The nurse is caring for a client recently admitted to the inpatient unit with a diagnosis of anorexia nervosa. The client has a known history of excessively exercising to avoid gaining weight. Which nursing action is most appropriate to address this behavior?  

A client with a diagnosis of Generalized Anxiety Disorder has been prescribed buspirone 15 mg daily by their healthcare provider. The client asks the nurse, “Why do I have to take this every day? My friend told me they take alprazolam and only have to take it when they feel anxious.” Which of the following responses by the nurse would be most appropriate to answer the client’s question?