The nurse is implementing the plan of care for a client.

For each body system, identify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention.

Each category must have at least one response option selected.

The patient is a 49-year-old male who has been experiencing flu-like symptoms, including fever and chest congestion, for 4 days.

He came to the emergency department (ED) last night when his breathing difficulties increased. He has a history of smoking half a pack of cigarettes a day for 20 years.

He has no significant medical or surgical history.

Which two orders should the nurse prioritize?

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying.
What interventions should the nurse include in this client’s plan of care? Select all that apply.

The nurse identifies several nursing problems for an older adult client with gastroenteritis who is experiencing fever, chills, anorexia, and diarrhea.
The client has a history of a stroke with left-sided hemiplegia and is dependent on care provided by the spouse. Which problem should the nurse determine has the highest priority?

The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position.
Which action should the nurse implement?

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

A patient with a history of adrenal insufficiency has been admitted to the intensive care unit due to an acute adrenal crisis.

The patient is experiencing nausea and joint pain.

The patient’s vital signs are as follows: temperature of 102 F (38.9° C), heart rate of 138 beats/minute, and blood pressure of 80/60 mm Hg. What is the first intervention the nurse should implement?

The nurse is collecting a heel-stick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid- stimulating hormone (TSH) levels, prior to discharging a 2-day-old patient.
When the parents ask why these tests are being conducted, which explanation should the nurse provide?

A client with end-stage Alzheimer’s disease is brought to the clinic by the caregiver for an appointment with the healthcare provider.

The caregiver speaks privately to the nurse about not sleeping well at night and experiencing frequent periods of crying.

Which intervention should the nurse implement?

A male adult is admitted due to an overdose of acetaminophen.

After being transferred to the mental health unit, the patient is informed that he has liver damage.

What is the most crucial information for the nurse to include in the patient’s discharge plan?

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm.
After confirming the presence of the spasms, which action should the nurse take?