A nurse is working on an inpatient mental health unit. A cli…
A nurse is working on an inpatient mental health unit. A client with schizophrenia becomes anxious, pacing, and says, “The TV is sending me messages.” In the dayroom, a second client with obsessive-compulsive disorder (OCD) is visibly distressed, repeatedly washing hands and stating, “If I don’t wash exactly 20 times, my family will die.” Nearby, a third client with borderline personality disorder begins yelling, “You never help anyone here!” Which nursing actions are appropriate? (Select all that apply)
Read DetailsA nurse is caring for a client who has schizophrenia and gen…
A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam (Xanax) 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?
Read DetailsA 38-year-old client diagnosed with schizophrenia began risp…
A 38-year-old client diagnosed with schizophrenia began risperidone (Risperdal) 2 mg PO daily 2 weeks ago. During today’s follow-up clinic visit, the client reports experiencing several side effects, including dry mouth, constipation, dizziness when standing, weight gain, and fatigue. Additionally, the client mentions a new episode of fever and severe muscle stiffness. For each finding in the table below, select the most appropriate nurse response. Response options include: Teach self-management strategies, Notify provider today, Immediate action required Finding Response Options Dry Mouth [Response1] Constipation x 4 days [Response2] Dizziness upon standing [Response3] Weight gain of 11 pounds in 2 weeks [Response4] Fever 103.1°F, severe rigidity, confusion [Response5]
Read DetailsA 58-year-old client with end-stage renal disease (ESRD) arr…
A 58-year-old client with end-stage renal disease (ESRD) arrives at the emergency department after missing two scheduled hemodialysis sessions. The client reports weakness, palpitations, and shortness of breath. The cardiac monitor shows peaked T waves. Upon assessment the client is noted to have labored breathing and crackles upon auscultation in all lung fields. Which provider orders should the nurse anticipate for this client? Select all that apply. Vital Signs Temperature 98.8 F Heart rate 52 bpm Blood pressure 158/92 mmHg Respiratory rate 25/min SpO2 91% on room air Laboratory Test Result Reference Range Potassium 6.9 mEq/L 3.5–5.0 mEq/L BUN 88 mg/dL 7–20 mg/dL Creatinine 9.8 mg/dL 0.6–1.3 mg/dL Blood Glucose 180 mg/dL 70–110 mg/dL
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