1. RN is assessing a family's dynamics during a counseling session. The
RN should recognize which of the following findings as an indication of a
boundary issue?: Older children who are responsible for their younger
siblings
-Ex. enmeshed boundaries - there are no distinctions between the roles
of the family members.
2. RN is performing an admission assessment on a client and notices that
the client appears withdrawn and fearful. To establish a trusting nurse-
client relationship, what action should the RN take first?: Inform the client
that this admission is confidential
-The RN should first inform the client about confidentiality during the
orientation phase of the nurse-client relationship.
3. RN is performing a cognitive assessment to distinguish delirium from de-
mentia in a client whose family reports episodes of confusion. What
assess- ment findings support the RN's suspicion of delirium?: Easily
distracted
,-extreme distractibility is a hallmark manifestations of delirium
4. RN caring for an older adult client who is experiencing delirium. What
interventions should the nurse include in the client's plan of care?: Permit
the client to perform daily rituals to decrease anxiety.
-The RN should provide the client with delirium a plan of care that
decreases agitation and anxiety by permitting the client to perform
daily rituals.
5.RN is planning care for a client who has bipolar disorder and is
experiencing mania. What interventions should the RN include in the plan of
care?: Offer the client high-calorie finger foods frequently
-The RN should frequently offer the client high-calorie foods that can
be eaten on the go. Clients experiencing mania might be unable to sit
down for meals and can experience weight loss and dehydration.
6. RN is teaching a partner of a client who has bipolar disorder how to
identify manifestations of acute mania. What findings should the client's
partner report to the provider?: Inability to sleep
, -During acute mania, the client is extremely active and does not sleep,
which can lead to exhaustion. Therefore the RN should instruct the
partner to report this finding.
7. RN is caring for a client who is experiencing a panic attack. What
actions should the RN take?: Assist the client with deep-breathing
exercises
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