A client is admitted to the hospital for alcohol intoxication. The family reports that he is a heavy drinker and has been admitted several times for alcohol detoxification. When can the nurse expect to observe the first symptoms of withdrawal?

While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?

Which statement made by the nurse would be most appropriate to an elderly client who is confused, has no history of dementia and is hospitalized for an acute urinary tract infection?

A nurse suspects the client is experiencing delirium. Which of the following assessment findings would support the nurse's suspicion?

The nurse observes a client drooling during mealtime. The client complains that his tongue feels swollen, and his jaw feels tight. What is the first action by the nurse?

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

An 80 year-old client, together with his daughter, arrived at the medical surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis?

The nurse is admitting a client with the diagnosis of schizophreniform disorder. What should the nurse expect to find?

Which nursing documentation entry accurately describes a client's use of confabulation?

Benztropine is ordered as needed (PRN) for a client taking haloperidol after being diagnosed with schizoaffective disorder.

Which of the following assessments by the nurse would indicate a need for this medication?

A client receiving risperidone reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing food and is drooling. The client is diaphoretic. By 1600, vital signs are as follows Temperature 102.8 F pulse 110 beats/minute, respirations 26 breaths/minute, and blood pressure 150/90 mmHg.

What is the nurse's best analysis and action?