The nurse and occupational therapist are planning an outdoor volleyball game and picnic for eight mental health clients. What action should the nurse take for the two clients taking nortriptyline (Pamelor) for depression?

The nurse is caring for an unstable cardiac client and must be prepared for a possible cardiopulmonary emergency. What is the most important preparation the nurse should include?

A nurse is standing next to a person eating fried shrimp at a parade. Suddenly, the man clutches at his throat and is unable to speak, cough, or breathe. The nurse asks the man if he’s choking, and he nods yes. What action should the nurse take next?

The nurse is caring for a hearing-impaired client in the coronary care unit. To reduce sensory overload for the client, it is most important for the nurse to do what?

The nurse on the rehabilitation unit is admitting a visually impaired elderly client for cardiac rehabilitation therapy. What plan should the nurse include to reduce sensory deprivation for a visually impaired client?

The nurse is instructing the client who will be discharged on anticoagulant therapy. Which of the following is an appropriate instruction?

The nurse is recording an electrocardiogram (ECG) for a client with a pacemaker in the cardiac clinic. He has had the fixed-rate pacemaker for many years and states that at times he feels funny and gets nauseated. The nurse interprets which ECG pattern as possible pacemaker malfunction?

The nurse is caring for a frail, elderly client. At the client care conference, the family asks if it is safe for him to receive narcotics for pain. The nurse is aware that the client is receiving hydromorphone hydrochloride (Dilaudid) for pain. What is the most appropriate response for the nurse to give the family?

The nurse is planning discharge instructions for the client going home on Coumadin (warfarin sodium). What is the priority teaching?

A nurse is caring for a client who has been diagnosed with alcoholism in an acute care mental health unit. The client has been referred to Alcoholics Anonymous (AA). Which statement best indicates that the client is ready to begin the AA program?

The home health nurse is instructing the mother of a child diagnosed with juvenile rheumatoid arthritis (JRA) on interventions to reduce the child’s pain and stiffness. What is the most appropriate intervention?

The nurse is assessing a laboring client. The client suddenly screams and states that the baby is coming. What is the priority action by the nurse?

A client has developed oral ulcerations secondary to chemotherapy agents. What is the most appropriate nursing intervention?

The psychiatric home health nurse arrives to visit a client with bipolar disorder. The client is swinging rapidly on the porch swing. She is wearing a red polka dot dress, large yellow hat, and heavy makeup with large gold jewelry. The nurse interprets the client’s behavior as evidence of which of the following?

The psychiatric home health nurse is planning care for a client with paranoid schizophrenia who was recently discharged from a mental health facility. Which nursing action should be included in the plan of care?

The nurse working in the telemetry unit notices a premature ventricular contraction (PVC) on the client’s monitor. While assessing the client, he states that he felt something “flip flop” in his chest. There are no other PVCs noted in the following hour. The nurse would make which documentation?

The nurse is assessing a client during a home health visit. The client complains of severe burning on urination. What is the most important information for the nurse to give the client?

A home health nurse is caring for a 4-year-old child diagnosed with juvenile rheumatoid arthritis (JRA). The mother tells the nurse she is concerned about the child’s posture. What is the most important information for the nurse to give the mother?

A pediatric nurse is caring for a 4-week-old neonate with severe colic. Which assessment finding does the nurse interpret as a sign of acute pain?

The nurse is caring for an 8-year-old child diagnosed with attention deficit hyperactivity disorder (ADHD) who has been running around the playroom for the past 15 minutes. Which behavior is the nurse most likely to observe in this client?

The mother of a middle school boy tells the school nurse she is concerned that her 13-year-old son may be depressed. Which behavior would the nurse expect the boy to exhibit?

The nurse is caring for a client who had a pacemaker inserted over 20 years ago. He has been admitted to the cardiac care unit with possible bacterial endocarditis. The nurse would expect which test to confirm the diagnosis of bacterial endocarditis?

The nurse is preparing a client for cardiac catheterization. What is the priority nursing communication?

The nurse is admitting a 35-year-old client to an inpatient substance abuse unit with a diagnosis of alcohol dependence. Which comment by the client would the nurse interpret as supporting this diagnosis?

The hospice bereavement nurse is conducting a family support group. During the session, a 56-year-old client, who recently lost his 82-year-old father to lung cancer, describes how he is responding to his loss. The bereavement nurse expects which sign of grief?

The nurse is caring for a 60-year-old male client suspected of having coronary artery disease. The physician has ordered a noninvasive diagnostic test to evaluate cardiac changes. The nurse prepares the client for which test?

The home health nurse is visiting a 72-year-old client with severe osteoarthritis. During the visit, the client tells the nurse that his wife died a year ago. Which statement by the client requires further intervention?

A 72-year-old client is being discharged from outpatient surgery after having a cataract removed from his right eye. Prior to discharging the client, it is most important for the nurse to teach the client to:

The nurse is caring for a burn client who is receiving total parenteral nutrition (TPN) at 75 ml/hour. The nurse is most concerned when the client experiences which symptom?

A home care aide notified the agency that she found a client lying on the floor. When the home health nurse arrives, she quickly assesses the newly diagnosed diabetic client. The assessment includes the following: client is semicomatose, apical heart rate is 102 beats/minute, blood pressure is 84/30 mm Hg, and skin is warm and dry. The nurse instructs the home care aide to call for an ambulance because these are signs of which condition?