UWorld NCLEX-RN QBank 2022 QUESTIONS AND ANSWERS ALL CORRECT
The nurse finds a client on the floor in the client's room. Based on the documentation
... [Show More] 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 Correct Answer: 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 Correct Answer: 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
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 Correct Answer: 2,3,5
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 appropriate weight gain and nutritional intake.
Nursing care includes:
•Determining minimum caloric intake for healthy weight gain and documentation of consumed calories and protein (Option 3)
•Establishing a weekly weight-gain goal - an appropriate goal for most clients is 2-3 lb/wk (0.91-1.36 kg/wk)
•Limiting physical activity initially and gradually increasing as oral intake improves
•Allowing client to make food choices, when possible, to give a sense of control
•Providing reflection with the client about behaviors, triggers, or situations that cause dysfunctional eating (Option 2)
•Weighing the client at the same time each day, after voiding, and wearing the same clothing to assess efficacy of nutritional support (Option 5)
(Option 1) Allowing the client with anorexia to continue exercising will cause further energy deficit, which can contribute to worsening malnutrition and end-organ damage (eg, renal failure).
(Option 4) Extensive focus on food intake (eg, food logs) should be avoided as it may increase the client's preoccupation with eating.
The health care provider (HCP) prescribes a 10-day course of amoxicillin for a 1-year-old diagnosed with acute otitis media (AOM). Which instruction is most important for the nurse to review with the child's parents?
1. Return to the office if the child does not improve within 48-72 hours
2. Stop the antibiotic if the child develops diarrhea
3. Stop the antibiotic if the child feels better after 72 hours
4. Use over-the-counter decongestants to help with recovery Correct Answer: 1. Return to the office if the child does not improve within 48-72 hours
Explanation: AOM is an infection of the middle ear. Potential complications of AOM include hearing loss and spread of the infection. To prevent permanent damage, severe cases of AOM are treated with antibiotics. Amoxicillin is the standard treatment in most cases. However, if AOM symptoms do not improve within 48-72 hours of initiating antibiotic therapy, the client should return for further assessment. The HCP will then assess for other causes of persistent symptoms and determine if a different antibiotic is required to treat drug-resistant organisms.
Following treatment with antibiotics, clients with AOM should be evaluated for complete infection resolution and screened for hearing impairment.
(Option 2) Diarrhea is a frequent side effect of amoxicillin therapy that does not warrant treatment discontinuation. If the client develops fever and abdominal pain associated with diarrhea, it may indicate Clostridium difficile superinfection; this should be reported to the HCP. The medication is stopped immediately if the child develops an allergic reaction (eg, rash, shortness of breath, throat tightness).
(Option 3) Ear pain and fever often subside within the first few days of antibiotic treatment. However, the entire course should be completed as prescribed to treat the infection completely and prevent antibiotic resistance.
(Option 4) Over-the-counter decongestants are ineffective for AOM treatment and may even delay the recovery process.
An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply.
1. Angle bottle up and toward cleft
2. Burping the infant often
3. Feeding in an upright position
4. Feeding slowly over 45 minutes or more
5. Using a specialty bottle or nipple Correct Answer: 2,3,5
Explanation: A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk:
•Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3).
•Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft.
•Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5).
•These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2).
•Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula.
•Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula.
(Option 1) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose.
(Option 4) Feeding should take about 20-30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth.
The nurse assesses a child who has been treated for an acute asthma exacerbation. Which client assessment is the best indicator that treatment has been effective?
1. Episodes of spasmodic coughing have decreased.
2. No wheezes are audible on chest auscultation [Show Less]