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Reason; Client who has major depressive disorder is capable of making health care decisions unless determined legally incompetent A nurse is admitting a client who has schizophrenia to an acute ca... re setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following Clang association Reason: Clang associations often rhymes or contains a string of words that can have the same beginning sound. 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 Reason: typical manifestation A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take Ask the client what the voices are saying Reason: to determine if the pt or others are at risk for injury A nurse is caring for an older adult 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 is upsetting you” Reason: The nurse us acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first Discuss the importance of hair with the client Reason: anticipatory grieving begins with acknowledging the importance of the expected loss A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data Sodium level 125 mEq/l Reason: In the presence of low sodium levels, renal excretion of lithium is reduces and the client is at risk for lithium toxicity. A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder (PTSD) [Show More]

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