A nurse is assisting in the care of a client who has schizophrenia. Which of the following entries should the nurse make to follow accurate documentation guidelines?

The client is admitted due to noncompliance at home.

The client uses neologisms when speaking to others.

The client is disruptive and annoying to other clients in the facility.

The client's partner is making their symptoms worse.

Answer and Explanation

The Correct Answer is B

Rationale:

A. The client is admitted due to noncompliance at home: The term "noncompliance" is vague and judgmental. Documentation should focus on specific behaviors or observations (e.g., "client was not taking prescribed medications") rather than generalizing or attributing motives.

B. The client uses neologisms when speaking to others: This statement is objective and describes a specific, observable behavior. Using clinical terms to document symptoms of schizophrenia aligns with accurate and professional documentation standards.

C. The client is disruptive and annoying to other clients in the facility: This phrasing is subjective and emotionally charged. Accurate documentation should avoid value-laden terms and instead describe the exact behavior (e.g., "client raised voice and interrupted group session").

D. The client's partner is making their symptoms worse: This is speculative and not based on objective observation. Unless the client specifically states this or it is directly witnessed, such assumptions should not be included in medical documentation.

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Correct Answer is A

Explanation

Rationale:

A. Preeclampsia: Methylergonovine causes vasoconstriction and increases blood pressure, which can be dangerous in clients with preeclampsia. Administering this medication in such cases can elevate the risk of stroke or seizure due to worsening hypertension.

B. An allergy to penicillin: Methylergonovine is not a penicillin-based medication, so a penicillin allergy does not present a known contraindication or concern. Caution is unnecessary unless there is a known allergy to ergot alkaloids.

C. Gestational diabetes mellitus: Methylergonovine does not significantly impact blood glucose levels or insulin sensitivity. Therefore, it can be used safely in clients with gestational diabetes when indicated for hemorrhage control.

D. Cholelithiasis: There is no direct interaction or exacerbation of gallbladder disease with methylergonovine. The medication primarily acts on uterine smooth muscle and vascular tone, not on the biliary system.

A. bone marrow failure B. hypernatremia C. malabsorption D. chronic respiratory infections E. excessive weight gain

Correct Answer is ["C","D"]

Explanation

Rationale:

• Chronic respiratory infections: A positive sweat chloride test confirms cystic fibrosis, a condition characterized by thick mucus that obstructs airways, leading to persistent cough, wheezing, and a high risk of recurrent lung infections due to impaired mucus clearance.

• Malabsorption: Cystic fibrosis affects the pancreas by blocking enzyme flow needed for digestion. This results in poor nutrient absorption, causing symptoms like excessive hunger, weight loss despite eating well, and abdominal distension, all of which are evident in this child.

• Bone marrow failure: There are no signs of pancytopenia, anemia, or infection susceptibility that would suggest bone marrow dysfunction. Cystic fibrosis does not typically impact hematopoietic function directly.

• Hypernatremia: Although cystic fibrosis can lead to salt imbalances due to abnormal chloride transport, hypernatremia is not commonly a presenting concern unless there's severe dehydration, which is not evident here.

• Excessive weight gain: The child is losing weight despite increased appetite. Malabsorption from pancreatic insufficiency prevents weight gain in cystic fibrosis, making excessive weight gain an unlikely risk.

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A nurse is assisting in the care of a client who has schizophrenia. Which of the following entries should the nurse make to follow accurate documentation guidelines?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who is experiencing a postpartum hemorrhage. For which of the following findings should the nurse proceed with caution when administering methylergonovine?

Correct Answer is A

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Explanation

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