A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:

• A.Must use the least restrictive measure possible to control the behavior
• B.Should put the client in seclusion until he promises to behave appropriately
• C.Should apply full restraints until the behavior is under control
• D.Should allow other clients to observe the acting out so that they can learn from the experience

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A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, "Something is wrong. This is like my labor." Which reply by the nurse identifies the physiological response of the client?

• A."Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract."
• B."Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement."
• C."The same hormone that is released in response to the baby's sucking, causing milk to flow, also causes the uterus to contract."
• D."There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it."

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A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:

• A.Notify the physician
• B.Place the client on a pad count
• C.Massage the uterus and re-evaluate in 30 minutes
• D.Have the client void and then re-evaluate the fundus

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A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?

• A."When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."
• B."If I have any side effects from my medicines, I will take an extra dose of Cogentin."
• C."When I get home, I should be able to taper myself off the Haldol because the voices are gone now."
• D."As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway."

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A client who has gout is most likely to form which type of renal calculi?

• A.Struvite stones
• B.Staghorn calculi
• C.Uric acid stones
• D.Calcium stones

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