A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth?

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

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?

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 is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?

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 about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile idiopathic arthritis. Which of the following interventions should the nurse include in the teaching?