RN 3.0 Clinical Judgment Practice 3
A nurse in an acute care setting is caring for a client who is experiencing an ischemic stroke. Exhibit 1, 2 A nurse in an acute care setting is caring for a client who is experiencing an ischemic stroke.
Cognition: - Initiate oxygen via nasal cannula Cardiac: - Initiate an antihypertensive medication - Stop alteplase
A nurse is admitting a client who has an eating disorder. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5 Select the 5 findings that require immediate follow-up. - Heart rate - WBC count - Skin turgor - Hemoglobin - Potassium level - Sodium level - Body temperature - Blood pressure - Chloride level
- Heart rate - Skin turgor - Potassium level - Blood pressure - Chloride level
A nurse is admitting a client who has an eating disorder. Exhibit 1, 2, 3, 4, 5 Click to highlight the findings in the client's medical record that indicate the client's condition is improving.
- Heart rate 100/min - Blood pressure 116/72 mm Hg - Potassium 3.5 mEq/L (3.5 to 5 mEq/L) - Chloride 99 mEq/L (98 to 106 mEq/L) - Weight 54.4 kg (120 lb) - Skin turgor immediate recoil - "I have been working with my dietitian regarding my diet and consuming an adequate amount of calories." - "I have not used any laxatives or diuretics, and I haven't made myself vomit." - "I have signed a behavioral contract with my therapist about my weight goals."
A nurse is admitting a client who has an eating disorder. Exhibit 1, 2, 3, 4, 5 For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
- Recheck the client's hemoglobin level: nonessential - Discuss binge-purge patterns with the client using direct questions: anticipated - Discuss manifestations of low potassium with the client: anticipated - Administer a diuretic to the client daily: contraindicated - Evaluate the client's nutritional patterns: anticipated - Administer bupropion orally to the client: contraindicated
A nurse is admitting a client who has an eating disorder. Exhibit 1, 2, 3, 4, 5 A nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. - Allow the client to provide input for developing an eating plan. - Stay with the client during meals and at least 1 hr following meals. - Encourage the client to develop a realistic perception of body image. - Recheck the client's electrolytes. - Weigh the client daily before first void. - Plan a progressive exercise program for the client. - Discuss thoughts that trigger binge behaviors. - Challenge irrational thoughts about food.
- Stay with the client during meals and at least 1 hr following meals. - Challenge irrational thoughts about food. - Discuss thoughts that trigger binge behaviors. - Recheck the client's electrolytes. - Encourage the client to develop a realistic perception of body image.
A nurse is admitting a client who has an eating disorder. Exhibit 1, 2, 3, 4, 5 Drag words from the choices below to fill in each blank in the following sentence. The nurse should first address the client's ______________ and _____________. - body image - feelings of sadness - social network - nutritional status - cardiac status
- cardiac status - nutritional status
A nurse is admitting a client who has an eating disorder. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5 For each client finding, click to specify if the finding is consistent with anorexia nervosa, bulimia nervosa, or binge eating. Each finding may support more than 1 disease process.
When analyzing cues, the nurse should determine that client manifestations of tachycardia, normal to slightly low body weight, lack of sense of control with overeating, parotid gland enlargement, ECG changes, and hypokalemia are consistent with the disease process of bulimia nervosa. A client who has anorexia nervosa exhibits clinical manifestations of bradycardia, low body weight, parotid gland enlargement, ECG changes, and hypokalemia. A client who has binge eating disorder presents with a lack of sense of control with overeating and obesity.
A nurse is caring for a client on a medical surgical unit. Exhibit 1, 2, 3, 4 Click to highlight below the interventions the nurse should take for each body system. To deselect an intervention, click on the intervention again.
When taking action, the nurse should apply oxygen and monitor the client's saturation continuously to ensure appropriate oxygenation because the client's saturation level has dropped. The nurse should administer the prescribed morphine because the client is experiencing an increased pain level. The nurse should change the client's dressing and assess the skin around the tubes to prevent any skin breakdown due to damp skin or pressure from the tube.