Uworld Nclex-Rn Qbank Exam With 100% Correct Answers | Verified | Latest Update

Uworld Nclex-Rn Qbank Exam With 100% Correct Answers | Verified | Latest Update The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time? 1 Found client lying on floor next to bed. Client states, "I fell out of bed while reaching for my eyeglasses and hit my head on the bedside table." Client is alert and oriented to time, place, person, and situation. Denies pain, dizziness, or nausea. No visible injuries. Assisted back to bed. Neurological vital signs within normal limits (see assessment flow sheet). Client instructed to use call bell for assistance. Will continue to monitor.__________RN 2 Health care provider (HCP) notified of fall. Prescribed CT of head STAT.___________RN 3 No change in neurologic status. Client to CT via gurney. Report filed per policy.__________RN 4 Client returned from CT. No change in neurologic status. Reinforced use of call bell, and - answer3 Explanation: All incidents, accidents, or occurrences that cause actual or potential harm to a client, employee, or visitor must be reported. The person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system using an electronic form. Alternately, a paper form may be completed and filed. The purposes of the report are to inform risk management of the occurrence, allowing them to consider changes that might prevent similar incidents, and to notify administration of a potential litigation claim. The nurse should not document that an incident report was filed, or refer to the incident report in the medical record. Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. 1. Amenorrhea 2. Fluid and electrolyte imbalances 3. Heat intolerance 4. Presence of lanugo 5. Refusal to exercise 6. Weight loss of 25% below normal weight - answer1,2,4,6 Explanation: Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: 1. Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. 2. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis 3. Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) 4. Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance 5. Lanugo (fine terminal hair) can be seen in extreme cases Manifestations of anorexia nervosa will resolve after the weight loss is corrected, although the recovery process can take several months. (Option 3) Anorexia nervosa manifests as cold intolerance. (Option 5) Anorexia nervosa manifests as lengthy and vigorous exercise. The nurse is helping to admit a client with malnutrition related to anorexia nervosa. Which actions are appropriate in the care of this client? Select all that apply. 1. Allow the client to continue to exercise per usual routine 2. Assist the client in reflection on triggers of disordered eating 3. Determine the client's required daily intake of calories 4. Encourage the client to keep a log of foods consumed 5. Monitor the client's weight at the same time each day - answer2,3,5 Explanation: Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients with anorexia exhibit preoccupation with body image and obsessive behaviors to lose weight (ie, excessive exercising/dieting). Clients commonly have protein-energy malnutrition and may be extremely underweight. Acute care focuses on restoring physiological integrity through approp