A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, “I can’t find my way home.” The patient is confused and unable to answer questions. Select the nurse’s best action.

During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patient’s hand. Select the correct analysis of the nurse’s behavior.

A patient diagnosed with schizophrenia tells the nurse, “The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say.” Which response by the nurse would be most therapeutic?

A person who feels unattractive repeatedly says, “Although I’m not beautiful, I am smart.” This is an example of:

A patient tells a nurse, “My new friend is the most perfect person one could imagine: kind, considerate, and good-looking. I can’t find a single flaw.” This patient is demonstrating:

A patient experiencing panic suddenly began running and shouting, “I’m going to explode!” Select the nurse’s best action.

The health care team at an inpatient psychiatric facility drafts these criteria for admission. Which criteria should be included in the final version of the admission policy? Select all that apply.

Which comments by a nurse demonstrate use of therapeutic communication techniques? Select all that apply.

The following is the nomogram used for titrating heparin infusions using AntiXa results. The patient’s AntiXa result comes back at 0.25. It is 0800, and the patient’s heparin is running at 12.5 units/kg/hr. According to the nomogram, what will the nurse do? SUGGESTED NOMOGRAM FOR HEPARIN DOSING USING ANTI-Xa MONITORING Heparin Activity (AntiXa) Level PRN Re-Bolus Change Infusion Rate Next Heparin Activity (AntiXa) Level < 0.20 units/ml 25 units/kg once, then increase by 4 units/kg/hr 6 hours after dose adjustment 0.20 - 0.29 units/ml none increase by 2 units/kg/hr 6 hours after dose adjustment 0.30 - 0.70 units/ml none No change in 6 hours x 1, then every AM 0.71 - 0.80 units/ml none decrease by 1 unit/kg/hr 6 hours after dose adjustment 0.81 - 0.99 units/ml none decrease by 2 units/kg/hr 6 hours after dose adjustment > 1.0 units/ml none Stop infusion for 1 hour,  then decrease by 3 units/kg/hr 6 hours after dose adjustment

A patient arrives in the emergency department with hemiparesis and dysarthria that started two hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for