A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?

A nurse is caring for an adolescent.
Admission Assessment
1400:

• Adolescent brought to emergency department by parents following a fall while skateboarding.
• Adolescent reports pain in . their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
• Adolescent is awake, alert, and oriented x 3.
• Lungs clear, respirations even and regular.
• S1 and S2 with regular rate and rhythm.
• Abdomen soft and nontender with active bowel sounds in all four quadrants.
• Right lower extremity with open wound and displaced bone.
• Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Which of the following actions should the nurse take after the adolescent returns from surgery?

Select all that apply.

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?

A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching?

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?

A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?

The nurse is assessing the adolescent 4 hr following fasciotomy. Highlight the findings below that indicate the adolescent's condition is improving.

Admission Assessment

1400:

Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.

Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Nurses' Notes 2300:

Adolescent is drowsy and reports nausea. Respirations shallow. Lungs clear. Unproductive cough present. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with hypoactive bowel sounds in all four quadrants. Right lower extremity fasciotomy, dressing clean, dry, and intact. Extremity pulse +3. Capillary refill 2 seconds. Right extremity is warm to the touch. Adolescent reports no numbness or tingling. Adolescent reports pain as 2 on a scale of 0 to 10.

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?