A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

Patient Data

The nurse engages the client in conversation about her feelings and some of her coping mechanisms.

Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one but may have more than one answer selected.

The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2.

Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse.

The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with:

• Fatigue
• Generalized weakness
• Muscle cramps
• Tingling sensation in her arms and legs
• Lightheadedness

She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.

Initial Vital Signs:

• Blood Pressure: 146/82 mmHg
• Heart Rate: 114 bpm
• Respiratory Rate: 18 bpm
• SpO₂: 98% on room air
• Temperature: 98.2 °F (36.8 °C) orally