A charge nurse is teaching a newly licensed nurse about the facility’s computerized documentation system.

Which of the following information should the nurse include?

Answer is… C and F indicate improvement.

A The client has gained 1.8 kg (4 lb). BMI is 18.9. This is not an improvement because the client’s BMI is still below the normal range of 18.5 to 24.9 The client may have malnutrition or other health problems that affect their weight.

B The clients adult child prepares two meals per day for the client. This is not an improvement because it shows that the client still depends on others for their basic needs and may have difficulty with self-care.

C The clients clothing is clean and appropriate for the weather. This is an improvement because it shows that the client has good hygiene and can dress themselves appropriately.

D The client receives three baths per week from a home care aide. This is not an improvement because it shows that the client still needs assistance with bathing and may have limited mobility or pain.

E The client reports frequent toothaches and lack of dental care. This is not an improvement because it shows that the client has poor oral health and may have infections or other complications.

F The client makes eye contact and smiles when speaking. This is an improvement because it shows that the client has positive mood and social interaction.

: https://www.hopkinsmedicine.org/health/conditions-and-diseases/distal-radius-fracture- wrist-fracture : https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.

Choice A reason

Weight loss is not the correct answer: Weight loss is not a common side effect of simvastatin. In fact, weight loss is generally not associated with statin use. If the client experiences significant, unintentional weight loss, it may indicate another underlying issue that should be reported to the provider.

Choice B reason:

Muscle weakness is the correct answer. The nurse should instruct the client to monitor and report any muscle weakness to the healthcare provider when taking simvastatin. Simvastatin is a statin medication used to lower cholesterol levels in the blood. While statins are generally well-tolerated, they can occasionally cause muscle-related side effects, including muscle weakness or pain.

Rhabdomyolysis, a severe condition characterized by the breakdown of muscle fibres, is a rare but serious side effect of statin use. Muscle weakness may be an early sign of this condition. Therefore, if the client experiences any unexplained or persistent muscle weakness while taking simvastatin, it should be reported to the healthcare provider immediately.

Choice C reason

Fever is not the correct answer: Fever is not a common side effect of simvastatin. If the client develops a fever while taking simvastatin, it is more likely to be related to another condition and should be reported to the provider for further evaluation.

Choice D reason:

Edema is the correct answer: Edema (swelling) is not a common side effect of simvastatin. If the client experiences significant edema, especially in the extremities, it may indicate another underlying issue that should be reported to the provider.