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, A nurse is performing a cognitive assessment to distinguish delirium from dementia in a
client whose family reports episodes of confusion. Which of the following assessment
findings supports the nurse's suspicion of delirium? - ANSWER-Easily distracted
A nurse is caring for a client who gave birth to a stillborn baby. Which of the following
statements should the nurse make? - ANSWER-"I'll stay with you just in case you want
to talk."
A nurse is caring for four clients in an emergency department. The nurse should identify
that which of the following clients can give informed consent? - ANSWER-A 35-year-old
client who has major depressive disorder
A nurse is teaching a newly licensed nurse about nursing care plans for clients who
have depressive disorders. Which of the following statements by the newly licensed
nurse indicates an understanding of the teaching? - ANSWER-"I will update the plan of
care as a client's manifestations of depression change."
A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago
following a motor-vehicle crash. The client's admission blood alcohol level was 325
mg/dL. Which of the following findings should indicate to the nurse that the client is
experiencing alcohol withdrawal? - ANSWER-Blood pressure 154/96 mm Hg
A nurse is planning care for a client who has made repeated physical threats toward
others on the unit. Although the client does not want to leave the unit, the nurse
requests the provider to transfer the client to a unit that is equipped to manage violent
behavior. Which of the following ethical principles should the nurse apply in this
situation? - ANSWER-Nonmaleficence
A nurse is discussing a 12-step program with a client who has alcohol use disorder and
is in an acute care facility undergoing detoxification. Which of the following information
should the nurse include in the teaching? - ANSWER-The client should obtain a
sponsor before discharge for an increased chance of recovery.
A nurse is creating a plan of care for a client who has been placed in seclusion after
threatening to harm others on the unit. Which of the following interventions should the
nurse include in the plan? - ANSWER-Renew the prescription for the client every 4 hr.