A nurse is caring for an older adult client.

Exhibits

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

System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not.. I found the title to the car today, signed over to me.
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom. Client reports not wanting to eat anymore. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A nurse is caring for a client who is 4 days postpartum following a cesarean birth.

For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.

A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate?

A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling?

A nurse is caring for a client.

For each assessment finding, click to specify if the finding is consistent with placenta previa or abruptio placenta. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void. Which of the following torts should the charge nurse identify as having occurred?

A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the report received during the shift report. Which of the following actions should the nurse take?

A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in- service? (Select all that apply.)

A nurse is caring for a client.

A nurse is continuing care for the client.

For each potential nursing action, click to specify if the nursing action is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A nurse is caring for a client in an acute care setting.

Complete the following sentence by using the list of options.

The client is at risk for

A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis. Which of the following actions should the nurse take?