What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

The primary caregiver of an elderly patient contacts the nurse at the outpatient clinic due to a sudden change in the patient’s behavior.

The caregiver informs the nurse that the patient, who is usually oriented and able to answer Questions, is now confused and agitated.

What actions should the nurse take? (Select all that apply)

A patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock.

The healthcare provider prescribes a sepsis protocol.

Which intervention is most important for the nurse to include in the plan of care?

A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes.
Which behaviors should the nurse prioritize for monitoring?

A client who follows Mormon beliefs is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply.

A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.

A client with diabetic ketoacidosis (DKA) is receiving an IV infusion of 0.9% sodium chloride and insulin.
Two hours later, the client’s serum laboratory results show a decrease in the serum blood glucose from 580 to 430 mg/dL (32.2 to 23.86 mmol/L). What additional laboratory result is most important for the nurse to monitor?

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy express that their child wants to continue attending swimming classes.
How should the nurse respond?

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 caregiver brings a client with end-stage Alzheimer’s disease to the clinic for an appointment with the healthcare provider.

The caregiver confides in the nurse about experiencing sleepless nights and frequent bouts of crying.

What action should the nurse take?

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?