VERIFIED CORRECT ANSWERS
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?
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?
"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?
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?
"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?
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?
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?
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?
Renew the prescription for the client every 4 hr.
A nurse is performing an admission assessment on a client and notices that the
client appears withdrawn and fearful. To establish a trusting nurse-client
relationship, which of the following actions should the nurse take first?
Inform the client that this admission is confidential.
A nurse is planning discharge teaching for a client who has severe
schizoaffective disorder. The nurse should identify that which of the following
treatment options can offer interdisciplinary services for the client at home?
Assertive community treatment