A 4-month-old with hydrocephalus is admitted to the hospital for shunt revision. When assessing for increased intracranial pressure, the nurse should observe the child for which finding(s)? Select all that apply.

A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

A client who was discharged 3 days ago after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen left lower leg. The nurse is preparing to initiate heparin therapy. Which additional intervention should the nurse include in this client's plan of care?

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

The nurse is caring for a client with anorexia nervosa who states, "I feel powerless when I gain weight." Which problem should the nurse identify as a priority?

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client verbalizes that he is tired of fighting this illness and is only continuing treatments because his family wants him to live. Which action should the nurse take?

The parents of an infant with chronic health conditions have cognitive challenges and diverse educational backgrounds. Which intervention(s) should the nurse implement to support them in safely administering medications to their child? Select all that apply.

A 14-year-old girl presents to the school nurse with the fourth vaginal yeast infection she has had during the past 6 months. The nurse should assess the adolescent for which finding(s)? Select all that apply.

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include a sodium of 129 mEq/L (129 mmol/L), a glucose of 54 mg/dL (2.97 mmol/L), and a potassium of 5.3 mEq/L (5.3 mmol/L). When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication?

Reference Range

Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Patient Data

Which of the following findings should the nurse recognize as manifestations of digoxin toxicity? (Select all that apply.)