1. The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST? 1.A patient was raped 30 minutes ago and expresses feelings of self-blame, anxiety, and worthlessness. 2.A patient indicates an intent to kill himself and says he has access to a gun. 3. A patient had a miscarriage last evening and is experiencing anger and resentment. 4. A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety. 2. The nurse in a small town is called to a neighbor’s house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. It is MOST important for the nurse to take which of the following actions? 1.Time the frequency of the contractions. 2. Assess the type of vaginal discharge. 3. Monitor the strength of the contractions. 4. Observe the perineum. 3. The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15 minutes by ambulance. Which of the following actions should the nurse take FIRST? 1. Contact the nursing supervisor. 2. Tell the emergency management team they will have to re-route 25 victims. 3. Activate the hospital’s disaster plan. 4. Inform the emergency department nurses they must work overtime. 4. As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse determines that further teaching is necessary if the client states which of the following?" 1. "This medication helps me with my depression." 2. "I will notify my physician if I show signs of hyperactivity and mania." 3. "I will see improvement in my symptoms in 1 to 4 weeks." 4. "If I experience a fever I will take Tylenol." 5. The nurse has just received change-of-shift report. Which of the following clients should the nurse see FIRST? 1. A client diagnosed with COPD with an PaO 2 of 70%. 2. A client diagnosed with type 1 diabetes who was just informed her husband is seriously injured. 3. A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement. 4. A client 10 hours postop after a right mastectomy complaining of wet sheets under her back. 6. The nurse instructs a mother of a child diagnosed with a myelomeningocele who developed an allergy to latex. The nurse determines that teaching is effective if the mother selects which menu for her child? 1. Guacamole with pita bread, lettuce, tomato juice. 2. Poached halibut, brown rice, carrots, peach cobbler. 3. Scrambled eggs, whole wheat toast, grapes, skim milk. 4. Baked chicken leg, mashed potatoes, spinach, milkshake. 7. The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculosis screening on which of the following children? 1. A child just returned from a 2-week trip to Europe. 2. A child recently moved to an apartment because the family lost their home. 3. A child with a new nanny who just emigrated from Latin America.