Difficulty: Medium
Average Score: 63%
Simulated
Passage / Scenario
History and PhysicalDay 1
1200:
Chief Complaint: ÔÇ£I donÔÇÖt know why they brought me here. IÔÇÖm fineÔÇØ
History of Presenting illness: Client is a 28-year- old female Client states they are admitted ÔÇ£because my family thinks I have issues with eating and that I'm too thin. I realize I don't eat that much, but I still need to lose weight. I gained 2 pounds in the last month!ÔÇØ The client reports no self-induced vomiting and ÔÇ£only sometimesÔÇØ uses laxatives. The client states IÔÇÖm anxious. I need to get out of here.ÔÇØ
Past Medical History: Generalized Anxiety Disorder
Social History: Client reports drinking 3 to 4 glass of wine every evening. Reports no tobacco or illicit drug use.
Physical Exam:
General: Cachectic
HEENT: No dental caries noted
Cardiovascular: S1. S1, no murmur, irregular rhythm
Respiratory: Bilateral breath sounds clear, respirations unlabored
Skin: Mild yellow hue to skin when blanched Lanugo to the face and back
Extremities: 1+ bilateral lower extremity edema
Vital Signs
Day 1
1200:
Temperature 37┬░C (98.6┬░F)
Heart rate 55/min
Respiratory rate 18/min
Blood pressure 89/58 mmHg
BMI 15.4 kg/m
Laboratory Results
Day 1
1200:
Potassium 2.8 mEq/L (3.5 to 5 mEq/L)
Day 1
1700:
Sodium 134mEq/L (136 to 145 mEq/L)
Chloride 94 mEq/L (98 to106 mEq/L)
Hemoglobin 12.4 g/dL (12 to 16 g/dL)
The nurse continues to care for the client Exhibits:The nurse is discussing the plan of care with the client. Select the 3 statements the nurse should make.
Correct answer
A,D,F
Rationale
Correct Answer: A, D, F
Rationale:
A: Creating an exercise plan once the client reaches their target weight is important for long-term health and maintenance.
D: Exploring thoughts that trigger rigorous exercise helps address potential unhealthy behaviors and promotes a balanced approach.
F: Setting a realistic weight gain goal supports the client's nutritional needs without promoting unhealthy weight gain.
Summary:
B: Monitoring blood pressure every other day may not be necessary unless there are specific concerns or medical conditions requiring frequent monitoring.
C: Eating independently to limit distractions during mealtime may not be appropriate for all clients and could potentially lead to social isolation.
E: Weighing the client every evening may create unnecessary stress and obsession with weight, which is not conducive to a healthy mindset.
Rationale:
A: Creating an exercise plan once the client reaches their target weight is important for long-term health and maintenance.
D: Exploring thoughts that trigger rigorous exercise helps address potential unhealthy behaviors and promotes a balanced approach.
F: Setting a realistic weight gain goal supports the client's nutritional needs without promoting unhealthy weight gain.
Summary:
B: Monitoring blood pressure every other day may not be necessary unless there are specific concerns or medical conditions requiring frequent monitoring.
C: Eating independently to limit distractions during mealtime may not be appropriate for all clients and could potentially lead to social isolation.
E: Weighing the client every evening may create unnecessary stress and obsession with weight, which is not conducive to a healthy mindset.