Mental Health 2020 B NGN

The nurse is caring for the client who has been placed in mechanical restraints and seclusion. Exhibit 1- History and Physical 36-year-old well-nourished female presents with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization. Client recently arrested for stealing money from parents to cover credit card charges and instigating physical altercations with current partner.Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for the past 12 years. Exhibit 2- Provider Prescriptions Day 1 Admit prescriptions: Regular diet Activity as tolerated Observe closely for self-injury or violence toward others. Buspirone 7.5 mg PO twice a day Haloperidol 2 mg IM every 3 hr PRN severe agitation Bacitracin ointment ¼ to ½ inch to arm and leg wounds 3 times daily Day 2 - 1215 Seclusion and mechanical restraint protocol. Exhibit 3- Medication Administration Record Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 Day 2 Buspirone 7.5 mg PO at 0800 Bacitracin ointment applied to leg and arm wounds at 0800 Haloperidol 2 mg IM left ventrogluteal at 1205 Exhibit 4- Nurses' Notes Day 1 - 0700 Admit note: Client is talkative, well-groomed.States they are "looking forward to divorcing partner number four" because she has "found my next partner."Anxious if left alone - wants to remain close to nurse. Tells the nurse, "I feel like a bomb waiting to explode." Day 2 - 1000 Client restless for past 2 hr. Pacing from bedroom to dayroom and mumbling to self. Argued with nurse this morning about attending group therapy session. Staring at staff members with fists clenched. 1200 Client is cursing at staff and other clients. Knocked over the card table in the dayroom. Attempted to hit one of the nursing staff. Haloperidol 2 mg IM administered left ventrogluteal at 1205 for severe agitation and violent outbursts. Placed in seclusion and mechanical four-point restraints as per facility policy for safety of client and others on unit. Provider informed and prescriptions received as per protocol. Exhibit 5- Diagnostic Results Day 1 - 0730 Hematocrit: 45% (female: 37% to 47%) Hemoglobin: 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose: 92 mg/dL (74 to 106 mg/dL) Exhibit 6- Graphic Record Day 1 - 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg Day 2 - 0900 Temperature 36.8° C (98.2° F) Heart rate 98/min Respiratory rate 20/min Blood pressure 118/78 mm Hg For each potential finding, click to specify if the finding indicates the client's condition has improved, not changed, or has declined. Potential Finding: Improved No Change Declined -Client attempts to bite nursing staff when offered water. -Client follows nurse's instructions. -Client is silent and glaring at staff. -Client verbalizes precipitating factors that lead to violent outburst.

Client attempts to bite nursing staff when offered water is an indication that the client's condition has declined. Client follows nurse's instructions is an indication that the client's condition has improved. Client is silent and glaring at staff is an indication that the client's condition has not changed. Client verbalizes precipitating factors that lead to violent outburst is an indication that the client's condition has improved.

A nurse is caring for a client who has borderline personality disorder. Exhibit 1: Nurses' Notes Day 1 - 0700 Admit note: Client is talkative, well-groomed.States they are "looking forward to divorcing partner number four" because she has "found my next partner."Anxious if left alone - wants to remain close to nurse.Tells the nurse, "I feel like a bomb waiting to explode." Exhibit 2: Diagnostic Results Day 1 - 0730 Hematocrit: 45% (female: 37% to 47%) Hemoglobin: 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose: 92 mg/dL (74 to 106 mg/dL) Exhibit 3: Graphic Record Day 1 - 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg Exhibit 4: History and Physical 36-year-old well-nourished female presents with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization.Client recently arrested for stealing money from parents to cover credit card charges and instigating physical altercations with current partner.Client attends a group exercise class twice a week and eats a well-balanced diet.Employed as legal secretary for the past 12 years. Exhibit 5: Provider Prescriptions Day 1 Admit prescriptions: Regular diet, Activity as tolerated, Observe closely for self-injury or violence toward others. Buspirone 7.5 mg PO twice a day, Haloperidol 2 mg IM every 3 hr PRN severe agitation, Bacitracin ointment ¼ to ½ inch to arm and leg wounds 3 times daily Exhibit 6: Medication Administration Record Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 Select the 6 findings found in the client's medical record that are indications of an exacerbation of a personality disorder. -Steals money from parents to cover credit card charges -Exercises twice a week -Anxious if left alone -Same job for 12 years -Well-nourished female -Hypersexualization -Well-groomed -Married multiple times -Incidences of self-injury -Physical altercations

-Steals money from parents to cover credit card charges is correct. -Anxious if left alone is correct. -Hypersexualization is correct. -Married multiple times -Incidences of self-injury is correct. -Physical altercations is correct.

A nurse is collecting data from a client whose home was destroyed in a fire? Which of the following responses should the nurse make first? A. "Are you experiencing feelings of hopelessness?" B. "Is there someone I can call for you?" C. "It might be helpful for you to attend a support group." D. "Now is a good time for you to use relaxation breathing."

A. "Are you experiencing feelings of hopelessness?" When using Maslow's hierarchy of needs, the priority action for the nurse to take is to determine if the client is safe. The nurse should collect data about the client's feelings to determine if the client is having feelings of hopelessness or suicidal ideations.

A nurse is caring for 4 clients who are displaying the use of defense mechanisms. Which of the following clients should the nurse identify as using a maladaptive defense mechanism? A. A client with multiple sclerosis stops taking their medication and says their diagnosis is wrong. B. An adolescent client who has difficulty with reading and becomes a star athlete. C. A client admires a highschool principal who seperated two students who were having a fight. D. A client who has a gambling disorder volunteers at a head start program.

A. A client with multiple sclerosis stops taking their medication and says their diagnosis is wrong. Suppression is the blocking of thoughts or feelings that a client finds unacceptable. Denying the presence of an illness is a maladaptive use of a defense mechanism.

A nurse is caring for a client who has depressive disorder and declines ECT despite the providers recommendation. Which of the following ethical principles is the nurse demonstrating by supporting the clients decision? A. Autonomy B. Nonmaleficence C. Fidelity D. Justice

A. Autonomy The nurse is demonstrating the principle of autonomy by respecting and supporting the client's right to make decisions about their treatment.

A nurse is collecting data from an older adult client who is postoperative following right knee arthroplasty. Exhibit 1: History and Physical Day 1 - 0800 75-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Client has operative knee in the continuous passive motion (CPM) machine, but attempts to take knee out of device. Client states, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, but oriented to self. Client refuses to answer simple questions, rambles incoherently when spoken to. Client will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. Family states that client was awake most of the night and was restless when they did fall asleep, and appeared to be having nightmares. Client attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee is dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Exhibit 3: Graphic Record Day 3 - 0800 Heart rate 115/minRespiratory rate 20/minBlood pressure 90/48 mm HgTemperature 38.6° C (101.5° F)Oxygen saturation 96% on room airWeight 63.5 kg (140 lb)Intake and Output (I&O)I = 750 mLO = 2,500 mL Exhibit 4: Provider Prescriptions Day 1 Enoxaparin 30 mg subcutaneously twice dailyLevothyroxine 75 mcg PO once dailyOmeprazole 20 mg PO once dailyPravastatin 40 mg PO once daily at bedtimeMorphine 2 to 4 mg intermittent IV bolus every 4 hr PRN painHydrocodone 5 mg PO every 6 hr PRN painAcetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Exhibit 4: Diagnostic Results Day 3 - 0800Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) Which of the following findings should the nurse report to the provider immediately? Select the 5 findings that require immediate follow-up. A. Cognitive awareness B. Oxygen saturation C. Blood pressure D. Surgical site E. Sleep/wake cycle F. I&O G. Blood glucose level H. Temperature

A. Cognitive awareness is correct. C. Blood pressure is correct. E. Sleep/wake cycle is correct. F. I&O is correct. H. Temperature is correct.

A nurse is participating in group therapy for clients who have major depressive disorder. Which of the following topics should the nurse include in the orientation phase of group therapy? A. Confidentiality B. Developing goals C. Problem solving D. Identifying the roles of group members

A. Confidentiality The nurse should establish the expectations of confidentiality during the orientation phase of group therapy.

A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? A. Elevated blood pressure B. Decreased heart rate C. Slurred speech D. Rhinorrhea

A. Elevated blood pressure Hypertension is an expected finding of alcohol withdrawal and can occur within 4 to 12 hr of cessation of alcohol ingestion.

A nurse is collecting data from a client who has delirium. The nurse should identify which of the following conditions as a predisposing factor for delirium? A. Hepatic failure B. Chronic alcohol use C. Hypertension D. Fluid volume overload

A. Hepatic failure Hepatic failure can be a predisposing factor for the development of delirium. Other potential predisposing factors include febrile illness, hypoxia, head trauma, and stroke.

A nurse is reinforcing teaching with a client who has a new prescription for phenelzine. The nurse should instruct the client that eating foods containing in tyramine can cause which of the following adverse reactions with this medication? A. Hypertensive crisis B. Serotonin syndrome C. Hearing loss D. Urinary incontinence

A. Hypertensive crisis Tyramine can cause severe hypertension in clients who are taking phenelzine, a monoamine oxidase inhibitor. Manifestations include palpitations, stiff neck, headache, nausea, vomiting, and elevated temperature.

A nurse is assisting in the morning hygiene care of a client who is cognitively impaired. Which of the following statements should the nurse make? A. Let me help you get your toothbrush." B. "Do you want to take a bath or brush your teeth first?" C. "Do you need help brushing your teeth?" D. "Let me inspect the inside of your mouth to see if your teeth are clean."

A. Let me help you get your toothbrush." A client who is cognitively impaired needs guidance in performing ADLs and should be given one simple task at a time.

A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following medications should the nurse expect to administer? A. Naltrexone B. Bupropion C. Varenicline D. Phenobarbital

A. Naltrexone The nurse should expect to administer naltrexone, an opioid antagonist, to a client who is experiencing opioid withdrawal.

A nurse is reviewing lab values of a client who has anorexia nervosa. Which of the following results should the nurse expect? A. Potassium 3 mEq/L B. Phosphorus 3.5 mg/dL C. Magnesium 1.8 mEq/L D. Cholesterol 165 mg/dL

A. Potassium 3 mEq/L The nurse should expect a client who has anorexia nervosa to have hypokalemia, which is indicated by a decreased potassium level. This value is below the expected reference range of 3.5 to 5 mEq/L.

A nurse is assisting with the plan of care for a client who is malnourished due to alcohol use disorder. Which of the following interventions should the nurse include in the plan? A. Restrict the client's sodium intake. B. Encourage the client to eat three large meals per day. C. Weigh the client weekly. D. Observe the client for 1 hr after they eat.

A. Restrict the client's sodium intake A client who is malnourished due to alcohol use disorder is at risk for ascites. Therefore, the nurse should restrict the client's sodium intake to decrease the risk for fluid retention.

A nurse is collecting data from a client who has agoraphobia. The nurse should identify that which of the following situations will increase the clients anxiety? A. Traveling in an airplane B. Entering a walk-in closet C. Taking a bath D. Picking up a soiled tissue

A. Traveling in an airplane The nurse should identify that using public transportation, such as traveling in an airplane, will increase the anxiety of a client who has agoraphobia.

A nurse is collecting data from a client who has major depressive disorder and is taking phenelzine. Which of the following findings should the nurse identify as an adverse effect of this medication? A. Weight gain B. Diarrhea C. Proteinuria D. Bleeding gums

A. Weight gain Weight gain, insomnia, and muscle cramps are adverse effects of phenelzine.

A nurse is caring for a client who is scheduled for ECT. Which of the following actions should the nurse take prior to the procedure? A. Keep the client in a side-lying position. B. Administer morphine IV. C. Prepare the client for intubation. D. Administer atropine sulfate IM.

D. Administer atropine sulfate IM. In preparation for ECT, the nurse should administer atropine sulfate IM 30 min prior to the procedure. This will decrease secretions in order to prevent aspiration that can be caused by the vagal stimulation induced by ECT.

A nurse is caring for a client who has borderline personality disorder. Exhibit 1: Nurses' Notes Day 1 - 0700 Admit note: Client is talkative, well-groomed.States they are "looking forward to divorcing partner number four" because she has "found my next partner."Anxious if left alone - wants to remain close to nurse.Tells the nurse, "I feel like a bomb waiting to explode." Day 2 - 1000 Client restless for past 2 hr. Pacing from bedroom to dayroom and mumbling to self. Argued with nurse this morning about attending group therapy session.Staring at staff members with fists clenched. Exhibit 2: Diagnostic Results Day 1 - 0730 Hematocrit: 45% (female: 37% to 47%) Hemoglobin: 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose: 92 mg/dL (74 to 106 mg/dL) Exhibit 3: Graphic Record Day 1 - 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg Day 2 - 0900 Temperature 36.8° C (98.2° F) Heart rate 98/min Respiratory rate 20/min Blood pressure 118/78 mm Hg Exhibit 4: History and Physical 36-year-old well-nourished female presents with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization. Client recently arrested for stealing money from parents to cover credit card charges and instigating physical altercations with current partner. Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as a legal secretary for the past 12 years. Exhibit 5: Provider Prescriptions Day 1 Admit prescriptions: Regular diet, Activity as tolerated, Observe closely for self-injury or violence toward others. Buspirone 7.5 mg PO twice a day, Haloperidol 2 mg IM every 3 hr PRN severe agitation, Bacitracin ointment ¼ to ½ inch to arm and leg wounds 3 times daily Exhibit 6: Medication Administration Record Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client. Potential Intervention: Anticipated Nonessential Contraindicated -Administer haloperidol 2 mg IM. -Hold next dose of buspirone. -Request change of diet to mechanical soft. -Request prescription for Digoxin 1 mg IV bolus stat. -Calmly approach client and state, "You seem agitated. Let's sit quietly and talk about it."

Administer haloperidol 2 mg IM is anticipated. Hold next dose of buspirone is contraindicated. Request change of diet to mechanical soft is nonessential. Request prescription for digoxin 1 mg IV bolus stat is contraindicated. Calmly approach client and state, "You seem agitated. Let's sit quietly and talk about it." is anticipated.

A nurse is collecting data from an older adult client who is postoperative following right knee arthroplasty. Exhibit 1: History and Physical Day 1 - 0800 75-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Client has operative knee in the continuous passive motion (CPM) machine, but attempts to take knee out of device. Client states, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, but oriented to self. Client refuses to answer simple questions, rambles incoherently when spoken to. Client will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. Family states that client was awake most of the night and was restless when they did fall asleep, and appeared to be having nightmares. Client attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee is dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Exhibit 3: Graphic Record Day 3 - 0800 Heart rate 115/minRespiratory rate 20/minBlood pressure 90/48 mm HgTemperature 38.6° C (101.5° F)Oxygen saturation 96% on room airWeight 63.5 kg (140 lb)Intake and Output (I&O)I = 750 mLO = 2,500 mL Exhibit 4: Provider Prescriptions Day 1 Enoxaparin 30 mg subcutaneously twice dailyLevothyroxine 75 mcg PO once dailyOmeprazole 20 mg PO once dailyPravastatin 40 mg PO once daily at bedtimeMorphine 2 to 4 mg intermittent IV bolus every 4 hr PRN painHydrocodone 5 mg PO every 6 hr PRN painAcetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Exhibit 4: Diagnostic Results Day 3 - 0800 Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Potential Order: Anticipated Nonessential Contraindicated Apply restraints Urinalysis with culture and sensitivity Melatonin Magnetic resonance imaging (MRI) of the head IV fluids

Apply restraints is contraindicated. Urinalysis with culture and sensitivity is anticipated. Melatonin is anticipated. MRI of the head is nonessential. IV fluids is anticipated.

A nurse is reinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the following statements should the nurse make? A. If you can control your actions this week, I'll talk to your parents about extending your curfew." B. "Have you considered participating in a sport to help control your aggression?" C. "If you become aggressive, your parents will take away privileges." D. "You're hurting others. Do you understand why that's wrong?"

B. "Have you considered participating in a sport to help control your aggression?" The nurse should encourage the client to participate in sports and other physical activities because they can provide a safer outlet for aggression.

A nurse is caring for a client who recently lost their child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask? A. "Are there times when you feel more upset than others?" B. "Have you had any thoughts of harming yourself?" C. "What type of support system do you currently have?" D. "During difficult times in the past, what did you do to cope?"

B. "Have you had any thoughts of harming yourself?" The greatest risk to this client is self-injury due to suicide. Asking whether or not the client has plans to hurt themselves is the most important question for the nurse to ask at this time because a positive response can alert the nurse to the need for suicide precautions and intervention.

A nurse is monitoring communication between a client who has alcohol use disorder and their partner. Which of the following communication pattern of the client's partner should the nurse identify as being effective? A. "I can never talk to you because you are always drunk." B. "I become very angry when you get drunk." C. "Because of your drinking, we can't have guests in our home." D. "Don't be mad at the kids. It was my fault that the dishes did not get done."

B. "I become very angry when you get drunk." The nurse should identify that this statement is an example of a healthy, effective communication pattern. The partner is discussing personal feelings instead of focusing on the client's negative behavior.

A nurse is caring for a client who was admitted with major depressive disorder (MDD) and states they do not want to attend group therapy. Which of the following responses should the nurse make? A. "Are you experiencing more feelings of depression?" B. "What are your feelings about going to group therapy?" C. "I know you'll make the right decision about going to group therapy." D. "You will feel better after going to group therapy."

B. "What are your feelings about going to group therapy?" The nurse should ask the client open-ended questions because they are therapeutic and allow the client to further discuss their feelings. The nurse should allow the client to discuss their feelings about group therapy in order to involve the client in their own care.

A nurse is attempting to resolve an ethical dilemma that involves a client's medical decisions and their own personal beliefs. After collecting data and identifying the problem, which of the following actions should the nurse take next? A. Discuss information about the dilemma with the client's provider. B. Determine the benefits and consequences of respecting the client's medical decisions. C. Reflect on the effect of ethical theories on the nurse's personal values. D. Develop a plan that balances both the nurse's values and the client's medical decisions.

B. Determine the benefits and consequences of respecting the client's medical decisions. After the nurse collects the data and identifies the problem, the nurse should determine the benefits and consequences of respecting the client's medical decisions as the next step in the ethical decision-making model.

A nurse is contributing to the plan of care for a client who has antisocial personality disorder. Which of the following short-term goals should the nurse recommend be included in the plan? A. The client will participate in assertiveness training. B. The client will discuss feelings that cause hostility. C. The client will describe an activity they found enjoyable. D. The client will dress in a manner appropriate for the setting and temperature.

B. The client will discuss feelings that cause hostility. Clients who have antisocial personality disorder are frequently aggressive and are at risk for injuring themselves or others. A short-term goal for these clients should be to discuss feelings that precipitate aggression or hostility.

A nurse is caring for a client who has borderline personality disorder. Exhibit 1: Nurses' Notes Day 1 - 0700 Admit note: Client is talkative, well-groomed.States they are "looking forward to divorcing partner number four" because she has "found my next partner."Anxious if left alone - wants to remain close to nurse.Tells the nurse, "I feel like a bomb waiting to explode." Exhibit 2: Diagnostic Results Day 1 - 0730 Hematocrit: 45% (female: 37% to 47%) Hemoglobin: 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose: 92 mg/dL (74 to 106 mg/dL) Exhibit 3: Graphic Record Day 1 - 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg Exhibit 4: History and Physical 36-year-old well-nourished female presents with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization. Client recently arrested for stealing money from parents to cover credit card charges and instigating physical altercations with current partner. Client attends a group exercise class twice a week and eats a well-balanced diet.Employed as legal secretary for the past 12 years. Exhibit 5: Provider Prescriptions Day 1 Admit prescriptions: Regular diet, Activity as tolerated, Observe closely for self-injury or violence toward others. Buspirone 7.5 mg PO twice a day, Haloperidol 2 mg IM every 3 hr PRN severe agitation, Bacitracin ointment ¼ to ½ inch to arm and leg wounds 3 times daily Exhibit 6: Medication Administration Record Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 For each potential provider's prescription, click to specify if the prescribed therapy is expected for obsessive-compulsive disorder, dementia, or borderline personality disorder. Each therapy can support more than 1 disease process. Prescribed Therapy: OCD Dementia Borderline personality disorder -Systematic desensitization -Validation therapy -Dialectical behavior therapy -Donepezil 5 mg PO daily -Fluoxetine 20 mg PO daily

Systematic desensitization is an expected therapy for obsessive-compulsive disorder. Validation therapy is an expected therapy for dementia. Dialectical behavior therapy is an expected therapy for borderline personality disorder. Donepezil 5 mg PO daily is an expected therapy for dementia. Fluoxetine 20 mg PO daily is an expected therapy for obsessive-compulsive disorder and borderline personality disorder.

A nurse is reinforcing teaching with the parent of an adolescent who has amphetamine use disorder. The nurse should identify which of the following statements by the parent indicates an understanding of the teaching? A. "I should be alert for weight gain in my child because this can indicate amphetamine use." B. "I can tell my child is using amphetamines because they are drowsy." C. "Dilated pupils are a sign that my child is using amphetamines." D. "Increased salivation can indicate that my child is using amphetamines."

C. "Dilated pupils are a sign that my child is using amphetamines." The nurse should instruct the parent to monitor the adolescent for mydriasis, or dilated pupils, because this is a manifestation of amphetamine use.

A nurse is reinforcing teaching with a caregiver of a client who has histrionic personality disorder. Which of the following manifestations should the nurse tell the caregiver to expect? A. Emotional detachment B. Paranoia C. Attention-seeking behavior D. Fear of abandonment

C. Attention-seeking behavior The nurse should identify that attention-seeking behavior, self-centeredness, and excessive emotionality are expected manifestations in a client who has histrionic personality disorder.

A nurse is reinforcing teaching with a client who has OCD and performs hand hygiene to decrease anxiety. Which of the following actions should the nurse make to demonstrate modeling as a behavioral intervention strategy? A. Setting a time limit in between episodes of hand hygiene B. Reminding the client to shout "stop" each time they have an urge to perform hand hygiene C. Demonstrating performing hand hygiene at appropriate times D. Instructing the client to practice muscle relaxation when they have the urge to perform hand hygiene

C. Demonstrating performing hand hygiene at appropriate times This action is an example of modeling, which is a strategy that allows the client to see another person perform the expected behavior.

The nurse is assisting with the admission of a client to an acute care mental health facility. Which of the following activities should the nurse plan for the working phase of a therapeutic nurse-client relationship? A. Define the specific responsibilities of the client and the nurse. B. Assist the client to establish mutual goals. C. Evaluate the client's progress toward meeting their goals. D. Discuss how the client can incorporate new strategies into their daily life.

C. Evaluate the client's progress toward meeting their goals. The nurse should evaluate the progress the client is making toward the goals they have established as part of the working phase of the therapeutic relationship. During the working phase, the nurse and the client identify and implement measures to help the client meet their goals.

A nurse in an inpatient mental health unit is supervising a group of clients in the unit's day room. The nurse fails to respond to the escalating, aggressive behavior of a client who eventually becomes violent and injures another client. For which of the following is the nurse liable? A. Battery B. Nonmaleficence C. Negligence D. Boundary violation

C. Negligence The nurse is liable for negligence by failing to respond to the client's escalating, aggressive behavior and prevent harm to others.

A nurse is reinforcing teaching about foods that contain tyramine with a client who has a prescription for phenelzine. Which of the following foods should the nurse instruct the client to avoid? A. Fried chicken B. Oranges C. Smoked sausage D. Lentils

C. Smoked sausage Smoked sausages are high in tyramine. Clients who are prescribed monoamine oxidase inhibitors (MAOIs) should avoid food that contain tyramine because consuming them can cause a hypertensive crisis.

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? A. Keep the client's room dark at night. B. Alternate the client's caregivers on a routine basis. C. Stand in front of the client when speaking. D. Remove personal belongings from the client's room.

C. Stand in front of the client when speaking. The nurse should stand in front of the client when speaking to them to maintain eye contact and maximize the client's understanding of the conversation.

A nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findings should the nurse withhold the clients medication and notify the provider. A. Fasting blood glucose B. Temperature C. WBC count D. Heartrate Exhibit 1: Graphic Record Blood pressure 102/52 mm Hg Respiratory rate 18/min Heart rate 100/min Temperature 37.8° C (100° F) SaO2​ 96% Weight 77 kg (169.8 lb) Height 177.8 cm (70 in) Exhibit 2: Diagnostic Results WBC count 3,000/mm3​​​ Hgb 14 g/dL Hct 42% Platelets 150,000/mm3​ Fasting blood glucose 107 mg/dL Exhibit 3: Provider Prescriptions Clozapine 200 mg PO daily Tramadol 50 mg PO every 6 hr Diphenhydramine 50 mg PO every 4 hr

C. WBC count The nurse should identify that a WBC count of 3,000/mm3 is below the expected reference range of 5,000 to 10,000/mm3. The nurse should identify that clozapine can cause agranulocytosis, a decrease in white blood cells, which can be life threatening. Therefore, the nurse should withhold the client's medications and notify the provider of this finding.

A nurse is caring for a client who states, "I just lost my job. This has been the worst day of my life." Which of the following responses should the nurse make? A. "You should focus on positive thoughts." B. "This job just wasn't a good fit for you." C. "You'll be able to find a better job soon." D. "Tell me about your day."

D. "Tell me about your day." The nurse should encourage the client to discuss the events of their day because this is a therapeutic communication technique that examines the client's perception of the day's events.

A nurse on a mental health unit is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following statement indicates an understanding of the teaching? A. "The consent form should be written at a seventh-grade reading level." B. "If the consent form is signed, I can send a client for a procedure even if they have questions." C. "I should explain everything to the client about the procedure before the client signs the consent form." D. "The consent form should have the name of the provider who is performing the procedure on the form."

D. "The consent form should have the name of the provider who is performing the procedure on the form." The consent form should include the name of the provider who will be performing the procedure. This should be present on the form before the client signs it.

A nurse is planning to collect data from a group of clients. A nurse should expect that which of the following clients is likely to exhibit speech pattern alterations? A. A client who has antisocial personality disorder B. A client who has dependent personality disorder C. A client who has bulimia nervosa D. A client who has schizophrenia

D. A client who has schizophrenia The nurse should expect a client who has schizophrenia to exhibit alterations in behavior, alterations in perception, and alterations in their speech pattern. Speech pattern alterations include associative looseness, clang association, neologisms, and echolalia.

A nurse on a mental health unit is caring for four clients who have schizophrenia. Which of the following clients should the nurse see first? A. A client who has anergia B. A client who demonstrates blunted affect C. A client who demonstrates concrete thinking D. A client who is experiencing command hallucinations

D. A client who is experiencing command hallucinations Because command hallucinations are a risk factor for violence, the greatest risk to this client is injury to self or others. Therefore, the nurse should see this client first.

A nurse is collecting data from a client with a history of cocaine use. Which of the following findings is an indication that the client is experiencing cocaine toxicity? A. Hypothermia B. Piloerection C. Somnolence D. Seizures

D. Seizures The nurse should expect a client who is experiencing cocaine toxicity to experience seizures. Other findings include severe anxiety, hallucinations, and paranoid thoughts.

A nurse is caring for a client who has schizophrenia and a prescription for haloperidol. The nurse should identify which of the following findings indicates a potential need for a PRN dose benzotropine? A. Sore throat B. Increased mental confusion C. Urinary retention D. Shuffling gait

D. Shuffling gait The nurse should identify that a shuffling gait can be indicative of the presence of pseudoparkinsonism, which can be treated with a PRN dose of benztropine.

A nurse is caring for a client who is taking lithium and reports presisant nausea and vomiting for 2 days. Which of the following lab values should the nurse report to the provider? A. Potassium 4.0 mEq/L B. Lithium 0.9 mEq/L C. BUN 12 mg/dL D. Sodium 132 mEq/L

D. Sodium 132 mEq/L The nurse should identify that a sodium level of 132 mEq/L is not within the expected reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to lithium accumulation and places the client at risk for lithium toxicity. The nurse should report this finding to the provider.

A nurse is caring for a client who is undergoing behavioral therapy for PTSD. The nurse should identify that which of the following findings indicates an improvement in the clients condition? A. The client reports about techniques they use to promote sleep. B. The client shows limited emotion when discussing witnessing a traumatic event. C. The client states that they no longer feel like they can trust their partner. D. The client avoids situations that might trigger memories of past trauma.

D. The client avoids situations that might trigger memories of past trauma. Clients who have PTSD frequently experience disrupted sleep. Therefore, reporting about techniques they use to promote sleep demonstrates that the client's condition has improved.

A nurse is collecting data from a client who is taking valproic acid for the treatment of BPD. Which of the following findings is priority to report to the provider? A. Dizziness B. Weight gain C. Constipation D. Yellow sclerae

D. Yellow sclerae When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is yellow sclerae because of the risk for hepatotoxicity.

A nurse is caring for a client who is experiencing delirium. Exhibit 1: History and Physical Day 1 - 0800 75-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Client has operative knee in the continuous passive motion (CPM) machine, but attempts to take knee out of device. Client states, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, but oriented to self. Client refuses to answer simple questions, rambles incoherently when spoken to. Client will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. Family states that client was awake most of the night and was restless when they did fall asleep, and appeared to be having nightmares. Client attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee is dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Day 3 - 0900 Return call from client's provider, update given, prescriptions received. Upon entering client's room, found client attempting to get out of bed. Client's family was trying to stop them. Client was agitated and disoriented to place, attempted to pull out IV device, and became incontinent of urine in the bed. Client's family stated, "That has never happened before."Reassurance offered to client and their family. Assistive personnel called to help with bathing the client and changing linens.Client calmer following hygiene and comfort measures. Reports having knee pain as 5 on a scale of 0 to 10. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Day 3 - 0930 Administered hydrocodone for knee pain. Client resting quietly. Family members at bedside. Exhibit 3: Graphic Record Day 3 - 0800 Heart rate 115/minRespiratory rate 20/minBlood pressure 90/48 mm HgTemperature 38.6° C (101.5° F)Oxygen saturation 96% on room airWeight 63.5 kg (140 lb)Intake and Output (I&O)I = 750 mLO = 2,500 mL Exhibit 4: Provider Prescriptions Day 1Enoxaparin 30 mg subcutaneously twice dailyLevothyroxine 75 mcg PO once dailyOmeprazole 20 mg PO once dailyPravastatin 40 mg PO once daily at bedtimeMorphine 2 to 4 mg intermittent IV bolus every 4 hr PRN painHydrocodone 5 mg PO every 6 hr PRN painAcetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Day 3 - 0900Obtain daily weightIV bolus of 0.9% sodium chloride 150 mL/hr for first 4 hr, then decrease to 75 mL/hrEncourage PO fluids.Urine for urinalysis and culture and sensitivityDiscontinue morphine.Melatonin 1 mg PO 2 hr before bedtime Exhibit 5: Diagnostic Results Day 3 - 0800 Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) Complete the following sentence by using the lists of options. The nurse should first (administer melatonin, obtain a urine specimen, assist with administering IV fluids) followed by (preparing discharge teaching, administering acetaminophen, weighting the client).

Dropdown 1 Assist with initiating IV fluids is correct. When using Maslow's hierarchy, the nurse should first assist with initiating IV fluids to supplement the client's oral intake. Based on the client's I&O status, the client's output is greater than their input, causing a fluid imbalance. This imbalance could be contributing to the client's manifestations of delirium. Dropdown 2 Administering acetaminophen is correct. When using Maslow's hierarchy, the nurse should administer acetaminophen based on the client's current temperature. The prescription states the medication should be administered for a temperature that is greater than 38.3° C (101° F). This fever could be contributing to the client's manifestations of delirium.

A nurse is caring for a client who has borderline personality disorder. Exhibit 1: Nurses' Notes Day 1 - 0700 Admit note: Client is talkative, well-groomed.States they are "looking forward to divorcing partner number four" because she has "found my next partner."Anxious if left alone - wants to remain close to nurse.Tells the nurse, "I feel like a bomb waiting to explode." Day 2 - 1000 Client restless for past 2 hr. Pacing from bedroom to dayroom and mumbling to self. Argued with nurse this morning about attending group therapy session.Staring at staff members with fists clenched. Exhibit 2: Diagnostic Results Day 1 - 0730 Hematocrit: 45% (female: 37% to 47%) Hemoglobin: 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose: 92 mg/dL (74 to 106 mg/dL) Exhibit 3: Graphic Record Day 1 - 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg Day 2 - 0900 Temperature 36.8° C (98.2° F) Heart rate 98/min Respiratory rate 20/min Blood pressure 118/78 mm Hg Exhibit 4: History and Physical 36-year-old well-nourished female presents with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization. Client recently arrested for stealing money from parents to cover credit card charges and instigating physical altercations with current partner. Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as a legal secretary for the past 12 years. Exhibit 5: Provider Prescriptions Day 1 Admit prescriptions: Regular diet, Activity as tolerated, Observe closely for self-injury or violence toward others. Buspirone 7.5 mg PO twice a day, Haloperidol 2 mg IM every 3 hr PRN severe agitation, Bacitracin ointment ¼ to ½ inch to arm and leg wounds 3 times daily Exhibit 6: Medication Administration Record Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 Complete the following sentence by using the lists of options. The client is at the highest risk for developing (hypertension, violent behavior, anemia, anorexia) as evidenced by the client's (heart rate, hematocrit, increased agitation, regular exercise).

Dropdown 1 Violent behavior is correct. The client is at the highest risk for developing violent behavior due to increased anxiety and agitation and a history of physical altercations. The nurse should monitor the client for signs of escalating agitation and aggressive behaviors. Dropdown 2 Increased agitation is correct. The client's history of physical altercations and statement of irritability indicate that the client is experiencing increased agitation.

A nurse is collecting data from an older adult client who is postoperative following right knee arthroplasty. Exhibit 1: History and Physical Day 1 - 080075-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Client has operative knee in the continuous passive motion (CPM) machine, but attempts to take knee out of device. Client states, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, but oriented to self. Client refuses to answer simple questions, rambles incoherently when spoken to. Client will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. Family states that client was awake most of the night and was restless when they did fall asleep, and appeared to be having nightmares. Client attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee is dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Exhibit 3: Graphic Record Day 3 - 0800Heart rate 115/minRespiratory rate 20/minBlood pressure 90/48 mm HgTemperature 38.6° C (101.5° F)Oxygen saturation 96% on room airWeight 63.5 kg (140 lb)Intake and Output (I&O)I = 750 mLO = 2,500 mL Exhibit 4: Provider Prescriptions Day 1:Enoxaparin 30 mg subcutaneously twice dailyLevothyroxine 75 mcg PO once dailyOmeprazole 20 mg PO once dailyPravastatin 40 mg PO once daily at bedtimeMorphine 2 to 4 mg intermittent IV bolus every 4 hr PRN painHydrocodone 5 mg PO every 6 hr PRN painAcetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Exhibit 5: Diagnostic Results Day 3 - 0800Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) A nurse is gathering data on a client who is displaying manifestations of delirium. Which of the following information from the client's medical record is a risk factor for delirium? Select all that apply. A. Hospital environment B. Older adult C. Family at bedside D. Postoperative E. Omeprazole use F. Enoxaparin use G. Fever

Hospital environment is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, the client's age, vision or hearing loss, recent surgical procedures, and infection. Older adult is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, the client's age, vision and hearing loss, recent surgical procedures, and infection. Postoperative is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, the client's age, vision or hearing loss, recent surgical procedures, and infection. Fever is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, the client's age, vision or hearing loss, recent surgical procedures, and infection.

A nurse is caring for a client who has a borderline personality disorder. Exhibit 1: Nurses' Notes Day 1 - 0700 Admit note: Client is talkative, and well-groomed. States they are "looking forward to divorcing partner number four" because she has "found my next partner."Anxious if left alone - wants to remain close to nurse. Tells the nurse, "I feel like a bomb waiting to explode." Day 2 - 1000 Client is restless for past 2 hr. Pacing from bedroom to dayroom and mumbling to self. Argued with nurse this morning about attending a group therapy session. Staring at staff members with fists clenched. Day 2 - 1200 Client is cursing at staff and other clients. Knocked over the card table in the day room. Attempted to hit one of the nursing staff.Haloperidol 2 mg IM administered left ventrogluteal at 1205 for severe agitation and violent outbursts. Placed in seclusion and mechanical four-point restraints as per facility policy for safety of client and others on unit. Provider informed and prescriptions received as per protocol. Exhibit 2: Diagnostic Results Day 1 - 0730 Hematocrit: 45% (female: 37% to 47%) Hemoglobin: 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose: 92 mg/dL (74 to 106 mg/dL) Exhibit 3: Graphic Record Day 1 - 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg Day 2 - 0900 Temperature 36.8° C (98.2° F) Heart rate 98/min Respiratory rate 20/min Blood pressure 118/78 mm Hg Exhibit 4: History and Physical 36-year-old well-nourished female presents with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization. Client recently arrested for stealing money from parents to cover credit card charges and instigating physical altercations with current partner. Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as a legal secretary for the past 12 years. Exhibit 5: Provider Prescriptions Day 1 Admit prescriptions: Regular diet, Activity as tolerated, Observe closely for self-injury or violence toward others. Buspirone 7.5 mg PO twice a day, Haloperidol 2 mg IM every 3 hr PRN severe agitation, Bacitracin ointment ¼ to ½ inch to arm and leg wounds 3 times daily Day 2 - 1215 Seclusion and mechanical restraint protocol. Exhibit 6: Medication Administration Record Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 Day 2 Buspirone 7.5 mg PO at 0800 Bacitracin ointment applied to leg and arm wounds at 0800 Haloperidol 2 mg IM left ventrogluteal at 1205 The nurse is caring for the client who has been placed in mechanical restraints and seclusion. Which of the following actions should the nurse take? Select all that apply. -Document the client's condition every 30 min. -Maintain continuous observation of the client while in restraints. -Remove two restraints at a time as the client regains control. -Maintain the client NPO during time in restraints. -Ensure the client is in prone position. -Conduct debriefing with the client and other staff.

Maintain continuous observation of the client while in restraints is correct. The nurse should ensure a staff member remains with the client continuously while the client is in restraints Conduct debriefing with the client and other staff is correct. The nurse should conduct debriefing with other staff to indicate the necessity of the intervention and to ensure that quality care is provided. The nurse should also talk with the client and discuss thoughts about what contributed to the intervention and strategies for crisis prevention in the future.

A nurse is caring for a client experiencing delirium. Exhibit 1: History and Physical Day 1 - 0800 75-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Client has operative knee in the continuous passive motion (CPM) machine, but attempts to take knee out of device. Client states, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, but oriented to self. Client refuses to answer simple questions, rambles incoherently when spoken to. Client will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. Family states that client was awake most of the night and was restless when they did fall asleep, and appeared to be having nightmares. Client attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee is dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Day 3 - 0900 Return call from client's provider, update given, prescriptions received. Upon entering client's room, found client attempting to get out of bed. Client's family was trying to stop them. Client was agitated and disoriented to place, attempted to pull out IV device, and became incontinent of urine in the bed. Client's family stated, "That has never happened before."Reassurance offered to client and their family. Assistive personnel called to help with bathing the client and changing linens.Client calmer following hygiene and comfort measures. Reports having knee pain as 5 on a scale of 0 to 10. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Day 3 - 0930 Administered hydrocodone for knee pain. Client resting quietly. Family members at bedside. Exhibit 3: Graphic Record Day 3 - 0800 Heart rate 115/minRespiratory rate 20/minBlood pressure 90/48 mm HgTemperature 38.6° C (101.5° F)Oxygen saturation 96% on room air Weight 63.5 kg (140 lb)Intake and Output (I&O)I = 750 mLO = 2,500 mL Exhibit 4: Provider Prescriptions Day 1Enoxaparin 30 mg subcutaneously twice dailyLevothyroxine 75 mcg PO once daily omeprazole 20 mg PO once dailyPravastatin 40 mg PO once daily at bedtimeMorphine 2 to 4 mg intermittent IV bolus every 4 hr PRN pain hydrocodone 5 mg PO every 6 hr PRN pain acetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Day 3 - 0900 Obtain daily weightIV bolus of 0.9% sodium chloride 150 mL/hr for first 4 hr, then decrease to 75 mL/hrEncourage PO fluids.Urine for urinalysis and culture and sensitivityDiscontinue morphine.Melatonin 1 mg PO 2 hr before bedtime Exhibit 5: Diagnostic Results Day 3 - 0800 Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) A nurse is caring for an older adult client who is postoperative and is experiencing delirium. Which of the following actions should the nurse take? Select all that apply. Offer the client warm milk at bedtime. Maintain a low stimulation environment for the client. Use detailed information when explaining care to the client. Turn off all the lights in the client's room. Approach the client from the front and speak slowly.

Offer the client warm milk at bedtime is correct. Maintain a low stimulation environment is correct Approach the client from the front and speak slowly is correct.

The nurse is reviewing the clients medical record. Exhibit 1: History and Physical Day 1 - 0800 75-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk. History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Client has operative knee in the continuous passive motion (CPM) machine, but attempts to take knee out of device. Client states, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, but oriented to self. Client refuses to answer simple questions, rambles incoherently when spoken to. Client will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. Family states that client was awake most of the night and was restless when they did fall asleep, and appeared to be having nightmares. Client attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee is dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Day 3 - 0900 Return call from client's provider, update given, prescriptions received. Upon entering the client's room, found the client attempting to get out of bed. The client's family was trying to stop them. The client was agitated and disoriented to place, attempted to pull out the IV device, and became incontinent of urine in the bed. The client's family stated, "That has never happened before."Reassurance was offered to the client and their family. Assistive personnel was called to help with bathing the client and changing linens. Client calmer following hygiene and comfort measures. Reports having knee pain as 5 on a scale of 0 to 10. Requested the client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Day 3 - 0930 Administered hydrocodone for knee pain. Client resting quietly. Family members at bedside. Day 4 - 0800 Client experienced confusion and insomnia through the night. Client-oriented to person, place, and time this morning. Appears fatigued. Incisional site clean, dry, and intact. Client ambulating with a walker during physical therapy three times daily. Physical therapy staff reports the client ambulating half the distance as previously able to - due to weakness and fatigue. The client reports pain as 2 on a scale of 0 to 10. Exhibit 3: Graphic Record Day 3 - 0800 Heart rate 115/minRespiratory rate 20/minBlood pressure 90/48 mm HgTemperature 38.6° C (101.5° F)Oxygen saturation 96% on room airWeight 63.5 kg (140 lb) Intake and Output (I&O)I = 750 mLO = 2,500 mL Day 4 - 0800 Heart rate 85/min respiratory rate 16/min blood pressure 126/68 mm HgTemperature 37.2° C (98.9° F)Oxygen saturation 98% on room air Weight 64.5 kg (142 lb) Intake and Output (I&O) = 1,950 mLO = 2,000 mL Exhibit 4: Provider Prescriptions Day 1 Enoxaparin 30 mg subcutaneously twice dailyLevothyroxine 75 mcg PO once daily omeprazole 20 mg PO once dailyPravastatin 40 mg PO once daily at bedtimeMorphine 2 to 4 mg intermittent IV bolus every 4 hr PRN pain hydrocodone 5 mg PO every 6 hr PRN pain acetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Day 3 - 0900 Obtain daily weightIV bolus of 0.9% sodium chloride 150 mL/hr for first 4 hr, then decrease to 75 mL/hrEncourage PO fluids.Urine for urinalysis and culture and sensitivityDiscontinue morphine.Melatonin 1 mg PO 2 hr before bedtime Exhibit 5: Diagnostic Results Day 3 - 0800 Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) Day 4 - 0800 Capillary blood glucose 102 mg/dL (82 to 115 mg/dL) Urinalysis:Urine specific gravity 1.008 (1.005 to 1.030)pH 6.5 (4.6 to 8.0) Protein 10 mg/dL (0 to 8 mg/dL)WBC count: many (none)RBC count: many (none) The nurse is evaluating the client's response to treatments. For each client finding, click to specify if the finding indicates an improvement, no change, or a decline in the client's condition. Client Findings Improvement No Change Decline Sleep/wake cycle Vital signs Daytime orientation Glucose level I&O Pain level Ambulation

Sleep/wake cycle indicates no change. The client continues to experience confusion and insomnia. Vital signs indicates improvement. All of the client's vital signs are within the expected reference ranges. Daytime orientation indicates improvement. The client is oriented to person, place, and time in the morning, indicating improvement in the client's condition. Glucose level indicates no change. The client's glucose level has remained unchanged and is within the expected reference range. I&O indicates improvement. The client's increased intake from the IV fluids has resolved the fluid imbalance. Pain level indicates improvement. The client's pain rating has dropped from a 5 to a 2 on a scale of 0 to 10, indicating that the client has responded positively to the administration of hydrocodone. Ambulation indicates a decline in condition. The client is not able to ambulate as far as before due to fatigue.