13. A parent brings a toddler to the pediatric clinic. The nurse observes a number of bruises on the child in various stages of healing. The parent claims the toddler bruises easily and falls a lot when they are trying to walk. The best action on the part of the nurse would be to:

49. A nurse is assisting with the care of a client who 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

33. A nurse is reinforcing teaching with a client who has a new prescription for phenytoin. The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

43. A client has returned from having a transurethral resection of the prostate.  The client is complaining of bladder discomfort and a feeling of urgency to void.  Which nursing action should be taken first?

15. A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following is the highest priority?

22. Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse assessed a pulse of 110, respirations at 28, and labored crackles in both lung fields. Which of the following actions by the nurse is priority?

17. A nurse is caring for a client on the psychiatric unit involuntarily admitted after attacking a neighbor. To keep the client in the hospital when the 72-hour hold is over, which of the following must be determined?

31. A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching?

18. A nurse is assisting in planning the care for client who has paranoid schizophrenia. Which of the following interventions is appropriate to recommend including in the plan of care?

4. The nurse is completing a history and physical on a patient who takes acetaminophen (Tylenol) daily basis for relief of generalized discomfort.  Which of the following indicates toxicity associated with the mediation?