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A psychiatric nurse has been working with a client who is experiencing a relapse of psychotic symptoms. Command hallucinations are ruled out, and the content of the auditory messages has been determined. What should the nurse's next planned intervention be? Teaching the client how to prevent relapses Instructing the client to eliminate dietary stimulants Helping the client learn strategies for disregarding the voices Assisting the client in recognizing hallucinations when they occur

Assisting the client in recognizing hallucinations when they occur

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. Bradycardia Hypotension Spastic paralysis Bladder dysfunction Increased pulse pressure

Bradycardia Hypotension Bladder dysfunction

The nurse is implementing measures to reorient a confused client post earthquake and suggests that a family member accompany the client. Which safety consideration is the nurse demonstrating? Patient identification Injury prevention for staff Injury prevention for clients Risk for errors and adverse events

Injury prevention for the client

The nurse is caring for a high-risk pregnant client who has had a positive contraction stress test (CST). What would the nurse interpret the result to mean? A nonstress test is needed. An immediate cesarean birth is needed. The fetal heart is within the expected limits for the average fetus. Late decelerations of the fetal heart rate are occurring with each contraction.

Late decelerations of the fetal heart rate are occurring with each contraction.

The registered nurse is appointed as a triage officer of the disaster management team. What would be the responsibility of the nurse as a triage officer? To decide the resources needed for the clients To determine the priority of treatment for clients To act as leader in implementing the emergency plan To serve as a liaison between the hospital and the media

To determine the priority of treatment for clients

Thirty minutes after administering fluphenazine to a client, the nurse notes that the client's jaw is rigid, the client is drooling, and speech is slurred. There are a number of as-needed prescriptions in the client's chart. Which will the nurse administer? Diazepam, 10 mg by mouth Trihexyphenidyl, 1 mg by mouth Haloperidol, 2 mg intramuscularly (IM) Benztropine, 2 mg IM

Benztropine (Cogentin), 2 mg intramuscularly7

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention? Initiate oxygen therapy Obtain chest x-ray film immediately Place client in a high-Fowler position Assess the client for a pleural friction rub

place the client in a fowlers position