A nurse is assisting with the plan of care for a client who has burns to his lower extremities.

Which of the following actions should the nurse include in the plan?

A nurse is caring for a newly admited older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.

Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.

Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.

Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Which of the following interventions should the nurse recommend to include in the client's plan of care?

Select all that apply.

A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect?

A nurse is caring for a newly admitted older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to the medical-surgical unit from the emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by an adult child.

Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.

The client is soft-spoken, speaks almost in a whisper, and does not make eye contact with the nurse.

The client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." The client's child states, "He gets confused sometimes. I can answer your questions."

Which of the following interventions should the nurse recommend to include in the client's plan of care?

Select all that apply.

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

A nurse is assisting with the development of an education program for a group of older adults. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

A nurse is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective?

A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?