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The nurse reviews the Nurses' Notes from Day 1 at 1100.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's

followed by the client .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for correct choices:

  • Electrolyte imbalance: The client’s potassium level of 3.0 mEq/L is critically low, contributing to premature ventricular contractions and orthostatic hypotension. These abnormalities place the client at immediate risk for cardiac dysrhythmias and require urgent correction to prevent life-threatening complications.
  • View of body: The client voices fear of gaining weight and fixates on food, which are indicators of distorted self-perception. This impaired view of the body is a central feature of bulimia nervosa and needs to be addressed during psychotherapy once the client is medically stabilized.

Rationale for incorrect choices:

  • Impaired body image: While body image concerns are common in eating disorders, this option is more general. “View of body” better captures the client’s psychological distortion and allows for more precise therapeutic interventions that address the cognitive roots of the disorder.
  • Impaired coping: The client engages in maladaptive coping strategies like bingeing and purging. However, these behaviors are secondary to deeper distortions in self-image and medical instability. Coping can be addressed later in the treatment process once safety is ensured.
  • History of anxiety: Anxiety is part of the client's long-standing history but is not causing the immediate physical risk. Addressing acute electrolyte disturbances and body image distortion takes precedence over chronic anxiety in this clinical setting.
  • Obsession with food: Although the client’s persistent thoughts about food are important, they are symptoms driven by distorted body perception. Treating the underlying belief system about body image is more foundational and effective in resolving food-related obsessions.


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Related Questions

Correct Answer is D

Explanation

Rationale:

A. Compare a list of common medications to treat a condition to the actual prescriptions: This approach does not meet the definition of medication reconciliation, which focuses on comparing the client’s actual prior medications to new orders to prevent errors.

B. Compare the prescription to the allergy history of the client: While this is an important safety check, it is not the primary purpose of medication reconciliation. Allergy review is a separate step done for every prescribed medication, not specifically during reconciliation.

C. Compare the medication label to the provider's prescription on three occasions before administration: This is part of the "three checks" of medication administration to ensure accuracy and safety, but it is unrelated to the reconciliation process that occurs during admission, transfer, or discharge.

D. Compare the client's list of home medications to the admission prescriptions written for the client: This is the central process in medication reconciliation. It ensures continuity of care, prevents omissions, duplications, or interactions, and identifies changes that need clarification.

Correct Answer is B

Explanation

Rationale:

A. Check the label of the medication twice prior to administration: Safe medication practice requires the nurse to check the medication label three times, when retrieving, preparing, and before administering to minimize the risk of medication errors.

B. Use two identifiers to verify the client's identity: Using two patient identifiers, such as name and date of birth, ensures the medication is given to the correct individual. This step is crucial for patient safety and is a core component of safe medication administration practices.

C. Document administration of the client's routine medications at the beginning of the shift: Medications should only be documented after they have been administered. Pre-charting medication administration can lead to errors if the medication is delayed, omitted, or refused.

D. Ensure the medication is administered within 3 hr of the scheduled time: Medications are typically required to be administered within 30 minutes to 1 hour of the scheduled time unless otherwise specified. A 3-hour window is too broad and may compromise therapeutic effectiveness.

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