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A nurse is teaching a newly licensed nurse about the importance of therapeutic communication. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears the client may go into withdrawal and require medical supervision. The client's manifestations included anxiety, tremors, BP 166/100 mm Hg, and tachypnea about 1 hr ago. Now the client begins yelling out that they are seeing spiders crawling all over the walls. They believe they are at home and begin calling for their mother. The nurse should recognize that the client is experiencing which of the following stages of alcohol withdrawal?

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.

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 receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

A nurse is providing teaching to a client about avoiding foods with tyramine. The client states, "Thank you for all of this information, but it's just not for me. I eat what I want when I want it." Which of the following stages of change is the client demonstrating?

A nurse is planning a teaching for a group of clients about defense mechanisms. Which of the following information should the nurse include? (Select All that Apply.)

A nurse is discussing borderline personality disorder and the risk for self-harm with a newly licensed nurse. Which of the following situations should the nurse identify as the highest risk for self-harm?

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 staff nurse reports an observation of a coworker injecting themselves with a syringe in the bathroom. The coworker admits to stealing narcotics from the medication room. The staff nurse should take which of the following courses of action?