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?
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At 0800, the nurse reviews the amount of T-tube drainage for…
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 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 n…
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:
A client with acute stress disorder states to the nurse, “I…
A client with acute stress disorder states to the nurse, “I keep having horrible nightmares about the car accident that killed my daughter. I should not have taken her with me to the store.” Which response by the nurse is most therapeutic?
A nurse is reviewing isolation precautions with a newly lice…
A nurse is reviewing isolation precautions with a newly licensed nurse on a medical-surgical unit. The nurse explains that droplet precautions are required for infections transmitted through large respiratory droplets that travel short distances (typically ≤ 3 feet). For which of the following conditions should the nurse implement droplet precautions? Select all that apply.
A client diagnosed with borderline personality disorder has…
A client diagnosed with borderline personality disorder has self-inflicted cuts on her arms. The nurse is assessing the client for the risk of suicide. What should the nurse ask the client first?
A nurse is providing education to a group of adults about ad…
A nurse is providing education to a group of adults about advance directives during a community health seminar. Which statements made by the participants indicate correct understanding of advance directives? Select all that apply.
The nurse is caring for four clients on a medical-surgical u…
The nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?
A multigravid client at 34 weeks’ gestation is being treated…
A multigravid client at 34 weeks’ gestation is being treated with indomethacin to halt preterm labor. If the client gives birth to a preterm infant, the nurse should notify the nursery personnel about this therapy because of the possibility for which complication?