A nurse is caring for a group of clients in a pediatric clinic.
Which of the following clients is at the highest risk for physical abuse? .

A nurse is collecting data from a client who has anorexia nervosa.
Which of the following findings should the nurse expect? (Select all that apply.) .

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

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.

0230: 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.

The client's adult child arrived at the ED and went to the client's room.

The client identified the family member.

The client is pacing and agitated and states, "I don't understand why I am here.”. The adult child asks the nurse to talk outside of the room and states, "I don't know why they are so confused.

They are not normally like this.”. The adult child.

Which of the following interventions should the nurse include in the client's care? Select the 3 interventions the nurse should implement.

Approach client slowly.

Alternate nursing staff daily.

Maintain a low stimulation environment.

Reorient client to person, place, and time frequently.

Provide the client with limited information about the diagnosis.

A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder.
Which of the following strategies should the nurse plan to use?.

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 is collecting data from an older adult client who was admitted with heart failure.
The nurse should report which of the following findings to the provider as an indication of delirium? .

A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.

A nurse is collecting data for a health history from a client who has antisocial personality disorder.
Which of the following clinical findings is associated with this disorder?.

A client is becoming increasingly agitated, anxious, and tense.
The nurse notes a clenched jaw and a change in the pitch of the client's voice.
Which of the following interventions should the nurse implement first?.

A nurse is caring for a client who has depressive disorder following the recent death of their partner.
Which of the following responses should the nurse make?.