UWorld NCLEX-RN QBank Latest 2023
Graded A
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 client
demonstrated understanding. Will continue to monitor.__________RN ✔✔3
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 ✔✔1,2,4,6
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
Graded A
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 client
demonstrated understanding. Will continue to monitor.__________RN ✔✔3
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 ✔✔1,2,4,6
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
