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A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

A nurse is caring for a client who ingested a selective serotonin reuptake inhibitor and St. John's Wort. Which of the following findings should the nurse identify as being consistent with serotonin syndrome?

A nurse is caring for a client. Which of the following client statements should the nurse identify as an indication of anorexia nervosa?

A nurse is caring for a client who is experiencing manifestations of anxiety. The nurse should recognize which of the following statements about the neurophysiologic manifestations of anxiety as correct?

A nurse at a primary care clinic is assessing a client for manifestations of depression. Which of the following client statements should the nurse identify as being consistent with depression?

A nurse in a mental health clinic is caring for a client who is grieving.

Nurses' Notes

1000:

Client presents to the mental health clinic and is tearful and angry recently experienced the loss of a child due to illness. Information provided to client about group therapy and individual therapy.

1100:

Client is continuing to sob and states, "I can't go on living without my child." Current list of home medications reviewed. Client states they have not been taking the prescribed medication "because it will not help."

1300:

Client spoke in group therapy session regarding feelings and prescribed treatment. Acknowledges the role of the therapist and expectations of support group, yet confides, "My anger and sadness are still very

Medication Administration

1000:

Sertraline 100 mg PO BID

Vital Signs

1015:

Temperature 36.8°C (98.4° F)

Heart rate 85/min

Respiratory rate 15/min

BP 147/86 mm Hg

Oxygen saturation 99%

A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address? Select all that apply.

A nurse is providing discharge teaching to a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?

A nurse on an inpatient mental health unit attends a training session about nurse burnout. The nurse should identify that burnout is most common in nurses who have which of the following traits?

A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met before the nurse can remove the restraints?

A nurse is caring for a client who has borderline personality disorder. Which of the following defense mechanisms is commonly used by clients who have this disorder and has the potential to create division amongst the healthcare team?

A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa.

Vital Signs

December 1:

Heart rate 48/min

Respiratory rate 24/min

Blood pressure 78/52 mm Hg Temperature 35.6° C (96° F)

SaO2 93% on room air

December 15:

Heart rate 55/min

Respiratory rate 20/min

History and Physical

December 1:

Height 163 cm (64 in)

Weight 34.5 kg (76 lb)

BMI 13

Pale, cold extremities, dry skin, thinning hair

Weak pulse

Respirations slightly labored, chest clear

Bowel sounds hypoactive x 4 quadrants

Concentrated urine

Laboratory Results

December 1:

Basic Metabolic Profile:

Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL)

BUN 30 mg/dL (10 to 20 mg/dL) Sodium 128 mEq/L (136 to 145 mEq/L) Potassium 3.1 mEq/L (3.5 to 5 mEq/L)

December 15:

Basic Metabolic Profile: Creatinine 0.9 mg/dL (0.5 to 1.0 mg/dL) BUN 22 mg/dL (10 to 20 mg/dL) Sodium 130 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5 to 5 mEq/L)

Height 163 cm (64 in) Weight 37.2 kg (82 lb) BMI 14.1 Pale, cold extremities, dry skin, thinning hair Pulses palpable Respirations even, unlabored, chest clear Bowel sounds active x 4 quadrants Clear yellow urine.

Diagnostic Results

December 1:

12 lead ECG: Sinus bradycardia

December 15:

12 lead ECG: Sinus bradycardia

A nurse on an inpatient eating disorder unit is assessing a client. Which of the following assessment findings indicate a therapeutic response to the treatment plan? Select all that apply.