A nurse in the ED assesses a 17-year-old patient. The patient’s friend reports that the patient had vomited in the car prior to arriving at the ED. Patient’s vital signs are T-97.3 F, B/P 98/52 mm hg, Apical pulse 46 bpm, RR 7 breaths per minute. The patient’s body feels cold, skin is pale and muscle tone is flaccid. Patient does not rouse to name, or physical stimuli. Which action should the nurse take first?

The nurse cares for a patient on their first day of inpatient alcohol detoxification. Which nursing intervention should the nurse do first?

The nurse working the emergency department cares  for a patient with Alzheimer’s who has sustained an injury that resulted in a fractured arm. The patient lives with his son who is also his caregiver. The caregiver cannot explain how the fracture occurred. Upon assessment the nurse notes the following: patient is malodorous, has urine soaked clothing and dried fecal matter lower extremities, has a stage 2 pressure ulcer on coccyx, bruising in various staging of healing on patient’s back and upper buttocks. Additionally the patient’s BMI is 16.4. Based on this information which action should be a priority for the nurse

The nurse is caring for a client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. Which should be the nurse’s initial intervention?

The nurse notes elevated levels of prolactin while reviewing the laboratory results of a client diagnosed with schizophrenia. Which symptoms should the nurse expect to assess? Select all that apply.

A patient who is being seen in the community mental health center for PTSD is being considered for EMDR. The nurse is asked to conduct an assessment to validate the client’s appropriateness for this treatment. Which of the following data, collected by the nurse, would be a contraindication for EMDR?

A 75-year-old client with a long history of depression is currently taking doxepin (Sinequan) 100 mg daily. The client also takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority?

2. Which indicates a client is likely demonstrating a mental disorder?

. A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the past 3 nights and a 12-lb weight loss over the past 2 weeks. Which should be this client’s priority nursing diagnosis?

The nurse prepares discharge teaching for a patient. The HCP has prescribed Alprazolam (Xanax), prn patient anxiety. Which client assessment finding would cause the nurse to question HCP’s order?