1. The nurse, on the mental health unit, is caring for a client who has had several verbal outbursts, is pacing around the unit and is at risk for assaultive behavior. Which of the following statements by the nurse would
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1. The nurse, on the mental health unit, is caring for a client who has had several verbal outbursts, is pacing around the unit and is at risk for assaultive behavior. Which of the following statements by the nurse would be most appropriate?
a. "Please take a time-out in your room."
2. The nurse is planning care for a client with moderate rheumatoid arthritis (RA). Which of the following nonpharmacologic interventions should the nurse include in the client's plan of care? Select all that apply.
a. Applying splints to rest inflamed joints,
b. Using Velcro fasteners on clothes to aid in dressing,
c. Applying moist heat to joints to relax muscles and relieve pain.
3. The nurse is planning care for a client who is newly diagnosed with human immunodeficiency virus (HIV). Which of the following prescribed prophylactic measures should the nurse include in the client's plan of care? Select all that apply.
a. Hep B b. Influenza
c. pneumococcal vaccines
4. The nurse is planning care for a client who has a recent diagnosis of multiple sclerosis (MS). Which of the following interventions should the nurse include in the client's care plan?
a. Encouraged to increase the fiber in his or her diet, void 30 minutes after drinking to help train the bladder and avoid constipation, and participate in daily muscle stretching to help alleviate and relax muscle spasms
5. The nurse is changing the descending colostomy for a client with a history of Crohn's disease. Which of the following findings should be a priority for the nurse to follow up?
a. A colostomy stoma should be bright, beefy red and moist. A dark purple-blue dry stoma may indicate compromised circulation or ischemia and a pale stoma can indicate anemia.
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