1. A nurse is planning care for a client following a suicide attempt.
• Provide the client with plastic eating utensils
2. A nurse is performing an admission assessment for a client who appears withdrawn and fearful.
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1. A nurse is planning care for a client following a suicide attempt.
• Provide the client with plastic eating utensils
2. A nurse is performing an admission assessment for a client who appears withdrawn and fearful.
• Inform the client that this admission is confidential
3. A nurse is caring for an adolescent client who has anorexia nervosa.
• “You’re afraid you have caused physical injury to yourself?
4. A nurse is caring for a client following a fire that destroyed her home and killed on of her children.
• Have you thought of harming yourself?
5. A nurse is checking laboratory values for a hospitalized young adult client who has bipolar disorder and is taking lithium.
• Serum creatinine 2.1
6. A nurse is providing information to a client who is seeking voluntary admission to a mental health facility.
• You will still need to give informed consent for treatments after admission
7. A nurse is developing a plan of care for an adolescent client who has conduct disorder.
• Initiate a behavioral contract with the client
8. A hospice nurse is talking with the family of a client who recently died from cancer following a series of chemotherapy treatments.
• Displacement
9. A nurse in an acute care facility is providing teaching for the adult child of an older adult client who is admitted with a urinary tract infection and delirium
• I expect that my father will no longer be confused when he is discharged
10. A nurse is caring for a client who is experiencing a manic episode.
• Encourage the client to rest each hour
11. A nurse is leading a medication education group for several clients. (select all that apply)
• Move others away from the client
• Offer the client a PRN dose of Lorazepam
• Ask the client open-ended questions about the behavior
12. A charge nurse is planning an in-service for a group of newly licensed nurses about the use of restraints.
• Record the client’s behavior every 15 minutes while in restraints
13. A nurse is assessing a client who has bulimia nervosa.
• Dental caries
14. A nurse is providing teaching to a client who has bipolar and has been taking lithium for 4 months.
• Limit outdoor exercise during hot weather.
15. A nurse on a mental health unit is conduction one-on-one session with a client who suddenly becomes silent.
• I’ve notices you have become quiet. Please share with me what you are thinking
16. A nurse is caring for a client who appears extremely agitated and believes that pacing the floor a specific number of times is necessary or “something terrible will happen”
• It must be hard for you to have to pace the floor. Let’s talk about your feelings
17. A nurse is discussing therapeutic communication with a group of newly licensed nurses
• And after that?
18. A nurse in a community program for clients who experience partner violence is planning secondary prevention strategies.
• Coordinating community resources for a hospitalized client
19. A nurse is caring for an adult client who was involuntarily admitted following a suicide attempt.
• I cannot discuss your spouse’s health information with you without his consent.
20. A nurse is planning to teach a group of clients about techniques to change unwanted behaviors.
• Role playing
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