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1. A nurse in an outpatient clinic is reviewing the medical record of a clientwho has
anorexia nervosa.
Click to highlight the information in the client's medical record that indicatethe client's
,condition is deteriorating. To deselect information, click on the information again.
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-QT prolongation
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-Exercise regimen Q
-Hematemesis
-Temperature
-Laxative use Q
-BMI: QT prolongation is correct. The finding of QT prolongation in the client's ECG
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during the second visit reveals cardiac complications of anorexia nervosa. Changes in
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electrolyte levels can shorten or prolong the QT interval. This is an indication that the
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Q client's condition is deteriorating.
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Exercise regimen is correct. The client's purchase of exercise equipment and work- ing
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out twice a day is a new manifestation of anorexia nervosa. This is an indication that
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Q the client's condition is deteriorating.
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Hematemesis is correct. New onset of hematemesis might be caused by esophageal
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irritation or ulceration due to the increase in the frequency of induction of vom- iting.
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Q Continued induction of vomiting can cause esophageal rupture. Therefore,
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,Q hematemesis is an indication that the client's condition is deteriorating.
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Temperature is incorrect. The client's temperature has remained within the expected
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reference range. A decrease in body temperature with cool skin is an indication that the
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Q client's condition is deteriorating.
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Laxative use is incorrect. The client's cessation of the use of laxatives is an indicationthat
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Q the client's condition is improving.
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BMI is correct. The client's BMI decreased between visits, which indicates the client is
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Q continuing to lose weight. This is an indication that the client's condition is
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deteriorating.
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2. A nurse is caring for an older adult client who has dementia and has wandered
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Q into the day room looking for their deceased partner. Which of thefollowing actions
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Q should the nurse take?
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, a. Move the client to a room near the nurses' station.
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b. Limit visitors until the client is oriented to the environment.
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c. Tell the client that their partner is deceased.
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d. Talk with the client about activities they enjoyed with their partner.: Ans- d. Talk
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with the client about activities they enjoyed with their partner.
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Talking about positive experiences can help distract the client from their disorienta-tion
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3. A nurse is caring for a client who has alcohol use disorder.
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Complete the following sentence by using the list of options.
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The client is at greatest risk for
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Dropdown 1:
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-Ineffective coping Q
-Dehydration
-Violent behavior Q
Dropdown 2: Q
-Agitation
-Loss of appetite Q Q