A client displaying acute mania is found pacing atop the pool table in the recreation room. She
waves a cue in one hand and gestures that she'll throw the pool balls if anyone comes near her. The
priority intervention is to
a. get her down off the table.
b. tell her she will be taken to seclusion.
c. clear the room of all clients.
d. assemble a show of force.
C
The safety of the other clients in the room is of primary importance. Once other clients are out of the
room, a plan for controlling this client can be implemented.
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The nurse assessing the client with systemic sclerosis (scleroderma) and sclerodactyly would anticipate finding what when examining the fingers?
1. Loss of pigmentation, or white patches 2. Hyperflexibility of the fingers 3. Excess collagen deposits in the skin layers 4. Lack of feeling in the first three fingers
A young adult patient has been taking an antidepressant medication for several weeks and reports having increased thoughts of suicide. The nurse questions further and learns that the patient has attempted suicide more than once in the past
The patient identifies a concrete plan for committing suicide. The nurse will contact the provider to discuss: a. changing the medication to another drug class. b. discontinuing the medication immediately. c. hospitalizing the patient for closer moni-toring. d. requiring more frequent clinic visits for this patient.
If you observe any signs of approaching death, tell the family first
True False
After cardiac surgery, a client's blood pressure measures 126/80. The nurse determines that the mean arterial pressure (MAP) is which of the following?
a. 46 mm Hg b. 80 mm Hg c. 95 mm Hg d. 90 mm Hg