• A nurse is caring for a client who has a history of depression and is experiencing a

situational crisis. Which of the following actions should thenurse take first?

• Confirm the client’s perception of the event

• Notify the client’s support system

• Help the client identify personalstrengths

• Teach the client relaxation techniques

• A nurse is caring for a client who has bipolar disorder and is experiencingacute mania.

The nurse obtained a verbal prescription for restraints. Which of the following should

the actions should the nurse take?

• Request a renewal of the prescription every 8 hr.

• Check the client’s peripheral pulse rate every 30 min

• Obtain a prescription for restraint within 4 hr.

• Document the client’s condition every 15 minutes.

• A nurse is working on a surgical unit is developing a care plan for a client who has

paraplegia. The client has an area of nonblanchable erythema over his ischium. Which

of thefollowing interventions should the nurse include in the care plan?

•

weight every 15 min while sitting