A nurse is assisting in the care of a client in the emergency department (ED). Nurses' Notes 0205: Client brought to the ED by police after being found wandering on the street.

Client able to provide identity to police but not able to identify place or time.

Family notified.

Client confused and agitated.

Appearance is disheveled.

Mucous membranes dry.

Lungs clear and equal, heart rhythm regular.

During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.

Vital Signs 0200: Temperature 38.6°C (101.5°F), Heart rate 104/min, Respiratory rate 18/min, Blood pressure 158/96 mm Hg, Oxygen saturation 98% on room air.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

A nurse is collecting data from a client who is experiencing opioid withdrawal.
Which of the following manifestations should the nurse expect?.

A nurse is collecting data from a client who has bulimia nervosa.
Which of the following findings should the nurse expect?.

A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder.
Which of the following statements by the parent indicates an understanding of the redirection technique? .

A nurse is contributing to the plan of care for a client who has a new prescription for lithium.
Which of the following interventions should the nurse recommend?.

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.

For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family.
Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.

A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency.
The nurse should encourage the client to participate in which of the following groups? .

A nurse is assisting with reminiscence therapy for a group of older adult clients.
Which of the following strategies should the nurse implement? .

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder.
Which of the following actions should the nurse take first? .

A nurse is collecting data from a client who experienced physical abuse as a child.
Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?.