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Ahnursehinhanhoutpatienthclinichishreviewinghthehmedicalhrecordhofhahclienthwhohhashanorexi
ahnervosa.
Clickhtohhighlighththehinformationhinhthehclient'shmedicalhrecordhthathindicatehthehclient'shcon
ditionhishdeteriorating.hTohdeselecthinformation,hclickhonhthehinformationhagain.
-QThprolongation
-Exercisehregimen
-Hematemesis
-Temperature
-Laxativehuse
-BMIh-
hCORRECThANSWERSQT hprolongationhishcorrect.hThehfindinghofhQThprolongationhinhtheh
client'shECGhduringhthehsecondhvisithrevealshcardiachcomplicationshofhanorexiahnervosa.hC
hangeshinhelectrolytehlevelshcanhshortenhorhprolonghthehQThinterval.hThishishanhindicationhth
aththehclient'shconditionhishdeteriorating.
Exercisehregimenhishcorrect.hThehclient'shpurchasehofhexercisehequipmenthandhworkinghout
htwicehahdayhishahnewhmanifestation hofhanorexiahnervosa.hThishishanhindicationhthaththehclie
nt'shconditionhishdeteriorating.
Hematemesishishcorrect.hNewhonsethofhhematemesishmighthbehcausedhbyhesophagealhirrit
ationhorhulcerationhduehtohthehincreasehinhthehfrequencyhofhinductionhofhvomiting.hContinue
dhinductionhofhvomitinghcanhcausehesophagealhrupture.hTherefore,hhematemesishishanhindi
cationhthaththehclient'shconditionhishdeteriorating.
Temperaturehishincorrect.hThehclient'shtemperaturehhashremainedhwithinhthehexpectedhrefe
rencehrange.hAhdecreasehinhbodyhtemperaturehwithhcoolhskinhishanhindicationhthaththehclient'
shconditionhishdeteriorating.
Laxativehusehishincorrect.hThehclient'shcessationhofhthehusehofhlaxativeshishanhindicationhthat
hthehclient'shconditionhishimproving.
BMIhishcorrect.hThehclient'shBMIhdecreasedhbetweenhvisits,hwhichhindicateshthehclienthishco
ntinuinghtohlosehweight.hThishishanhindicationhthaththehclient'shconditionhishdeteriorating.
Ahnursehishcaringhforhanholderhadulthclienthwhohhashdementiahandhhashwanderedhintohthehda
yhroomhlookinghforhtheirhdeceasedhpartner.hWhichhofhthehfollowinghactionshshouldhthehnurse
htake?
a.hMovehthehclienthtohahroomhnearhthehnurses'hstation.
b.hLimithvisitorshuntilhthehclienthishorientedhtohthehenvironment.
c.hTellhthehclienththaththeirhpartnerhishdeceased.
,d.hTalkhwithhthehclienthabouthactivitieshtheyhenjoyedhwithhtheirhpartner.h-
hCORRECThANSWERSd.hTalkhwithhthehclienthabouthactivitieshtheyhenjoyedhwithhtheirhpartn
er.
Talkinghabouthpositivehexperienceshcanhhelphdistracththehclienthfromhtheirhdisorientation
Ahnursehishcaringhforhahclienthwhohhashalcoholhusehdisorder.
Completehthehfollowinghsentencehbyhusinghthehlisthofhoptions.
Thehclienthishathgreatesthriskhforh______hashevidencedhbyhthehclient'sh______.
Dropdownh1:
-Ineffectivehcoping
-Dehydration
-Violenthbehaviorh
Dropdownh2:
-Agitation
-Losshofhappetite
-Inabilityhtohperformhsimplehtasksh-hCORRECThANSWERSDrophdownh1:
Ineffectivehcopinghishincorrect.hThehnursehshouldhcontinuehtohmonitorhthehclienthforhineffecti
vehcopinghandhencouragehthehclienthtohusehcopinghtechniques.hHowever,hthishishnoththehgre
atesthriskhforhthishclient.
Dehydrationhishincorrect.hThehnursehshouldhmonitorhthehclient'shintakehandhencouragehtheh
clienthtoheathandhdrink.hHowever,hthishishnoththehgreatesthriskhforhthishclient.
Violenthbehaviorhishcorrect.hThehgreatesthriskhforhthehclienthishengaginghinhviolenthbehaviorh
duehtohthehwithdrawalhofhalcohol,hwhichhishcausinghthemhincreasinghagitation.hThehnursehsh
ouldhcloselyhmonitorhthehclienthandhbehpreparedhtohintervenehtohprotecththehclienthandhother
shfromhinjury.
Dropdownh2:hAgitationhishcorrect.hThehclienthishathgreatesthriskhofhengaginghinhviolenthbehav
iorhashevidencedhbyhthehclient'shagitation,hwhichhcanhbehindicatedhbyhpacing,hrestlessness,h
staring,hsilence,hrigidhposture,handhclenchedhjaw.hThehnursehshouldhcloselyhmonitorhthehcli
enthandhbehpreparedhtohintervenehtohprotecththehclienthandhothershfromhinjury.
Losshofhappetitehishincorrect.hThehnursehshouldhmonitorhthehclient'shintakehandhencourageht
hehclienthtoheathandhdrink.hHowever,hthishishnoththehgreatesthriskhforhthehclient.hLosshofhappe
titehishanhexpectedhfindinghforhahclienthwhohishexperiencinghalcoholhwithdrawal.
Inabilityhtohperformhsimplehtaskshishincorrect.hThehnursehshouldhmonitorhthehclient'shabilityht
ohperformhsimplehtaskshandhencouragehusehofhcopinghstrategies.hHowever,hthishishnoththehg
reatesthriskhforhthehclient.
Ahnursehonhahmentalhhealthhunithishadmittinghahclienthwhohhashbipolarhdisorder.
Completehthehfollowinghsentencehbyhusinghthehlisthofhoptions.
, Thehfirsthactionhthehnursehshouldhtakehishtohaddresshthehclient'sh______hduehtohthehclient'sh
______.h-
hCORRECThANSWERSWhenhprioritizinghhypotheses,hthehnursehshouldhidentifyhthehgreat
esthriskhtohthehclienthishcardiovascularhinjuryhduehtohconstanthpsychomotorhactivity.hThehclie
nthishpacing,hmovingharmshandhhandsharoundhdramatically,handhishunablehtohsithstill.hThishca
nhincreasehthehclient'shbloodhpressurehandhhearthrate,hwhichhcanhindicatehunexpectedhcard
iovascularhfindings.
Ahnursehishteachinghahgrouphofhnewlyhlicensedhnurseshabouththehusehofhmechanicalhrestrai
nts.hWhichhofhthehfollowinghinformationhshouldhthehnursehincludehinhthehteaching?
a.hCompletehdocumentationhabouththehclient'shstatusheveryhhourhwhilehtheyharehinhrestraint
s.
b.hMaintainhthehclienthinhrestraintshforhahminimumhofh4hhr.
c.hApplyhrestraintshwhenhotherhmeanshofhmanaginghthehclient'shbehaviorhhavehfailed.
d.hRequesththaththehproviderhassesshthehclienthwithinh8hhrhofhthehapplicationhofhrestraints.h-
hCORRECThANSWERSc.hApplyhrestraintshwhenhotherhmeanshofhmanaginghthehclient'shbe
haviorhhavehfailed.
AccordinghtohthehPatienthSelf-
DeterminationhAct,hclientshhavehahrighthtohbehfreehfromhrestraintshorhseclusionhunlesshthehs
afetyhofhthehclienthorhothershishathrisk.hDe-
escalationhmethodshforhcontrollinghbehaviorhshouldhbehattemptedhpriorhtohinitiatinghrestrain
ts.
Ahnursehishpreparinghtohparticipatehinhanhinterdisciplinaryhconferencehforhahclienthwhohhashb
ipolarhdisorder.hWhichhofhthehfollowinghbehaviorshishthehpriorityhforhthehnursehtohreporthtohth
ehtreatmenthteam?
a.hCallinghfamilyhmembers
b.hSpendinghtimehalone
c.hGivinghawayhpossessions
d.hExcessivehcryingh-hCORRECThANSWERSc.hGivinghawayhpossessions
Givinghawayhpossessionshindicateshthaththishclienthishathgreatesthriskhforhsuicide.hTherefore
,hthishishthehpriorityhfindinghforhthehnursehtohreporthtohthehtreatmenthteam.
Ahnursehishteachinghahclienthwhohhashahdepressivehdisorderhabouthfluoxetine.hWhichhofhtheh
followinghinformationhshouldhthehnursehincludehinhthehteaching?
a.h"Youhmighthnoticehanhincreasehinhsalivahwhilehtakinghthishmedication."
b.h"Youhmighthexperiencehdifficultieshwithhsexualhfunctioninghwhilehtakinghthishmedication."h
c.h"Youhshouldhexpecthanhimprovementhinhsymptomshofhdepressionhinh3htoh4hdays."
d.h"Youhmayhnoticehahtemporaryhringinghinhthehearshwhenhstartinghthishmedication."h-
hCORRECThANSWERSb.h"Youhmighthexperiencehdifficultieshwithhsexualhfunctioninghwhile
htakinghthishmedication."h