Ati part b

A nurse is preparing to administer diazepam 7.5 MGIV bolus to the client for alcohol withdrawal available diazepam injections of 5 mg. How many milliliters should the nurse administer

1.5 ml if bolus

A nurse is caring for four clients in an emergency department. The nurse should identify Which of the following clients can give informed consent

A 35-year-old client who has major depressive disorder A client who has major depressive disorder is capable of making healthcare decisions unless the client is determined to be legally incompetent

A nurse is receiving change of shift report for for clients. Which of the following client should the nurse plan to see first

A client who is taking clozapine and reports a sore throat and chills When using urgent versus non-urgent approach the client care, the nurse should determine to first see the client who is taking clozapine reports sore throat and chills. Clozapine can cause agranulocytosis a serious adverse effect that causes neutropenia. The nurse should withhold medication to notify the provider of these findings

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve Which of the following adverse effects

Acute dystonia The nursery minister benztropine, and anti-cholinergic agent, to relieve a cute dystonia, which is the extra pyramid or adverse effect of chlorpromazine

A nurse in the emergency department is caring for for our clients. Which of the following clients is a nurse required to report as a potential victim of abuse

An older adult client who is bedbound and has a stage four pressure ulcer A stage four pressure ulcer on an older dog client who is bedbound can indicate physical neglect and warrants mandatory reporting

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching

Apply restraints when other means of managing the clients behavior have failed According to the patient self-determination act, clients have a right to be free from restraints or seclusion unless the safety of the clients or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints

A nurse is facilitating a community meeting for acute care clients. One client is constantly Talking and using the majority of the groups time. Which of the following intervention should the nurse implement

Ask group members to discuss their feelings about their clients monopolizing behavior This intervention will validate other members feelings toward the client who is dominating the meeting. It also should encourage group problem-solving

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder the nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home

Assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualize needs. Services are available in any setting including the clients home, 24 hour per day and provide crisis intervention, medication services and advocacy

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Assist the client with deep breathing exercises Relaxation techniques, such as deep, abdominal breathing exercises, help the diffuse manifestations of anxiety

A nurse on a medical surgical unit is assessing a client who has sustained injuries 12 hours ago following the motorcycle vehicle crash. The client admission blood alcohol level was 325 mg. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal

Blood pressure 154/96 mm hg Physical manifestations of alcohol withdrawal occur in addition to the psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3°C. It will be important for the nurse to rule out infection in the client who has a fever

A nurse on a mental health unit observed the client who has acute mania hit another client. Which of the following actions should the nurse take first

Call for a team of staff members to help with the situation The greatest risk is injury to the client and others. Therefore the first action the nurse should take is to call for assistance to prevent further injury to themselves or others

A nurse on an accurate mental health facility is receiving change of shift report for for clients. Which of the following client should the nurse assess first

Client who is experiencing delusions of persecution The presence of delusions of persecution indicate that the client is at greater risk for injury due to clients believe that a person in power is out to harm them. Therefore, the nurse assist the client first

A charge nurse on the mental health unit is disgusting client rights with a newly licensed nurse. Which of the following statements to the charge nurse make

Clients who are made in voluntarily maintain the right to give informed consent for procedures Clients who are admitted and voluntarily maintain the right to give Informed consent for treatment. They also have the right to give informed consent for procedures

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self directed injury or injuring others

Command hallucinations A client who has schizophrenia and is experiencing command hallucinations can hear voices telling them to hurt themselves or others. Therefore, a client who is experiencing command hallucinations is at the greatest risk for self directed injury or injuring others

A nurse is assessing a family dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue

Older children who are responsible for their younger siblings This is an example of enmeshed boundaries in which there are no distinctions between the rows of family members

A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include

Early identification of changes, such as decrease social involvement, is important Decrease social involvement is a manifestation of depression, and early identification of findings can lead to early intervention

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment finding supports the nurses suspicion of delirium

Easily distracted Extreme distractibility is a hallmark manifestation of delirium

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention

Establish screening programs to identify at risk clients This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for partner violence in the community and can take the necessary steps to address individual client needs

A nurse in the community health center is teaching families of clients who have post Trumatic stress disorder about expected clinical manifestations. Which of the following manifestations should the nurse include

Experiences feelings of isolation The nurse should expect clients who have PTSD to feel estranged and detached from others

A nurse is preparing to participate in an inter-disciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse report to the treatment team

Giving away possessions Giving away possessions indicates that this client is at greatest risk for suicide. Therefore, this is the priority fighting for the nurse to report to the treatment team

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for one week which of the following outcome should the nurse expect

Greater risk for attempting suicide as affect and energy and improve The nurse should identify that an initial response to amitriptyline can develop in one week. For a client who has major depressive disorder was suicidal aviation the energy to carry out a plan is increased after one week of treatment

A nurse in the community health center is working with a group of clients who have post Trumatic stress disorder. Which of the following intervention should the nurse include to reduce anxiety among the group members

Guided imagery Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety and clients who have posttraumatic stress disorder

A nurse is assessing a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness

I am going to order a wheelchair for when I'm unable to walk The client is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, which indicates the behavioral response of acceptance

A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client partner indicates an understanding of the teaching

I will not take charge of my partnerswork responsibilities The nurse should identify that it is important for the individual who has substance use disorder to take charge of personal responsibilities

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of teaching

I will talk about my feelings with a close friend Discussing feelings, such as fear and depression, with a support person is in effective coping strategy and can provide the client with emotional support and other resources

A nurse is teaching a new license nurse about nursing care plans for clients who have Depressive disorders. Which of the following statements by the new license nurse indicates an understanding of the teaching

I will update the plan of care as a clients manifestations of depression change The nurse should update the plan of care as a client status and needs change

A nurse is caring for a client who gave birth to a stillborn baby which of the following statements should the nurse make

I'll stay with you just in case you want to talk This response demonstrates the therapeutic communication techniques of offering self and indicates the nurses interest in the client and a desire to understand the clients feelings

A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan

Identify signs of escalation of violence It is important for the client to be able to identify signs of escalation of violence, which are the greatest risk to the client. Therefore, this is the first component of the safe plan because it increases awareness of danger Is imminent and it is time to leave

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following intervention should the nurse include in the plan

Identify the clients trigger foods The nurse should identify the trigger foods that initiate the clients binge and assess the client to understand their thoughts and behaviors that relate to the food

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the clients partner report to the provider

Inability to sleep During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding

A nurse is caring for a client who has alcoholic cardiomyopathy which of the following lab findings should the nurse expect

Increased creatinine phosphokinase An increase in CPK, a muscle enzyme released when muscle tissue is damaged occurs with cardiomyopathy

A nurse is performing an admission assessment on a client and notices that the client appears with John and fearful. To establish a trusting nurse client relationship, which of the following actions should the nurse take first

Inform the client that the submission is confidential According to evidence-based practice, the nursery first inform the client about confidentiality during the orientation phase or the nurse client relationship

A nurse observes the client on a mental health unit pushing on the locked unit door. We should be following statements should the nurse make

It appears as though you would like to open the door This statement is an example of a therapeutic technique of making observations. This technique and encourages the client noticed the behavior so that they can describe thoughts and feelings related to the behavior

A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness

It is important for our child to have regular dental check ups For a client who has bulimia nervosa, repeated vomiting erodes tea and predisposes the teeth to Cari's. Thus, the nurse should teach the guardians that regular dental check ups are important for a client who has bulimia nervosa

The school nurse is assessing a school-age child who experienced the traumatic loss of a parent eight months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder

Lack of interest in an upcoming holiday The child who has PTSD will have negative moods and difficulty remembering aspects of the Trumatic event. The child can also have a loss of interest or lack of participation in significant activities and events such as holidays

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching

Language delay The nurse should identify the language delays as a manifestation of autism spectrum disorder

A nurse is caring for an older dog client who begins to cry and states, I knew God would punish me and I deserve this horrible sickness which of the following responses should the nurse make

Let's talk about what's upsetting you The nurse is acknowledging the clients concerns and is showing a desire to understand what the client is thinking and feeling

A nurse is planning care for a client who has generalized anxiety disorder. Which of the following levels of anxiety to the nurse plan to teach the client relaxation techniques

Mild The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information

A nurse is planning care for a client who is to undergo electroconvulsive therapy which of the following actions should the nurse include in the plan

Monitor the clients cardiac rhythm during the procedure The seizure INDUCED dURING ECT can stress the clients heart. Therefore, the nurse should plan to monitor the clients cardiac rhythm during ECT via electrocardiogram

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, my roommate never sleeps and keeps me up to. Which of the following actions should the nurse take

Move the client who has bipolar disorder to a private room Clients who have bipolar disorder can disrupt a therapeutic Milieu for other clients. Therefore, the nurse should move this client to a private room

A nurse is planning care for a client who has made repeated physical threats towards others on the unit. Although the client does not want to leave the unit, the nurse request the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles to the nurse supply in the situation

Nonmaleficence It is the responsibility of the nurse to do no harm to clients. The nurse is applying at the good principle of nonmaleficence finished by requesting to transfer this client to a unit better able to manage their behavior in there by prevent injury to others on the unit

A nurse is preparing to discharge to home and older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs which of the following refers to the nurse initiate

Occupational therapy, meal delivery, physical therapy, and home health services

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following intervention should the nurse include in the plan of care

Offered the client high calorie finger foods frequently The nurse should frequently offer the client high calorie foods that can be eaten while the client is on the go. Client experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration

A nurse is caring for an older adult client who is experiencing delirium. Which of the following intervention should the nurse include in the clients plan of care

Permit the client to perform daily rituals to decrease anxiety The nurse should provide a client who has delirium with a plan of care that decrease his agitation and anxiety by permitting the client to perform daily rituals

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over the counter medications that the client reports taking should alert the nurse to a potential adverse reaction

Phenyleprine Clients who are taking tranylcypromine a MAOI antidepressant, should not take phenylephrine And other over-the-counter medications for sinus congestion, codes, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions as a priority

Reduce environmental stimuli The greatest risk to the child and others as harm. Therefore, the nurses priority intervention is to reduce environmental stimuli in an attempt to D escalate the behavior and prevent injury

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following intervention should the nurse include in the plan

Renew the prescription for the client every four hours The nurse should assess the clients behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every four hours, for a maximum of 24 hours

A person is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect

Rhinorrhea The nurse should expect a client who is experiencing Opiuo which I have rhinorrhea and flu like manifestations such as yawning, sneezing, and abdominal pain

A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had A fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the clients diagnosis

She won't let me take the trash from her room. I'm concerned about what she has in there The client might binge eat an attempt to hide food containers, which is a common behavior among clients who have bulimia nervosa. The parent statement indicates awareness of the clients behavior

A nurse on the mental health unit is caring for a group of clients which of the following actions by the nurse is an example of the ethical principle of justice

Spending adequate time with a client who is verbally abusive By spending adequate time with the client was verbally abusive the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and keeping their individual needs, the nurse guarantees that all clients receive equal care

A nurse in a mental health clinic is planning care for for clients. Which of the following Tasha the nurse delegate to an assistive personnel

Stay with a client who has anorexia nervosa for one hour after meal times Staying with a client who has anorexia nervosa following mealtimes is within the range of function of assistive personnel. Assistive personnel are allowed to attend to the safety of clients who are stable, and this test does not require assessment or a technical skill

A nurse in a mental health clinic is caring for a client who has posttraumatic stress disorder after returning from military deployment. Which of the following is a priority action for the nurse to take

Stay with the client when flashbacks occur The greatest risk to the client is injury that can occur during a flashback, therefore, the priority intervention for the nurses to remain with the client and offer reassurance and support when flashbacks occur

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take

Suggest forming a weekly support group for parents who have experienced the death of a child Support groups are a positive resource in the process of recovery for parents following the death of a child

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate

Tachycardia The nurse should monitor the child for tachycardia which is an adverse effect of methylphenidate

A nurse is assessing a client for respecters for the development of depression. The nurse should identify that which of the following factors place as a client at an increased risk for depression

The client has COPD The nurse should identify the clients who have a chronic medical illness are at an increased risk for development of depression

A nurse is discussing a 12 step program with a client who has alcohol use disorder and is An acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching

The client should obtain a sponsor before discharge for an increased chance of recovery The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings

Tooth erosion A client who has bulimia nervosa is likely to have a dental caries into the Razhan caused by frequent exposure to gastric acid from vomiting

A nurse at a providers office is interviewing an older dog client. Which of the following actions should the nurse plan to take

Use a screen tool to evaluate the client for depression Depression can be under diagnosed among older dog clients. The nurse should identify several risk factors for depression for the clients data including having Alzheimer's disease anxiety and the loss of a loved one. Manifestations of depression can also be nonspecific for older dog clients and can include weight loss, decreased energy levels, and difficulty sleeping

A nurse is reviewing lab results for a client who has schizophrenia and is taking clozapine. Which of the following value should the nurseIdentify as a contraindication for receiving clozapine

WBC count 2500/mm3

A nurse is counseling and adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states I'm so fat I can't even stand to look at myself. Which of the following therapeutic response demonstrates the nurses use of summarizing

You're saying that you think you are fat and are using laxative because you're afraid of gaining weight The nurse is using therapeutic technique of summarizing to review the key points of the discussion