For each of the provider's potential prescriptions, click to specify if the potential prescription is anticipated, nonessential, or
contraindicated for the client.
CT scan of brain is nonessential
Monitor vital signs every 30 min is anticipated.
Obtain an Alcohol Use Disorders Identification Test (AUDIT) is nonessential.
Initiate IV access is anticipated
Administer an anti-anxiety medication is anticipated.
Wake the client every 30 min for neurological assessment is contraindicated.
For each of the client assessment findings below, click to specify if the finding is consistent with alcohol toxicity or major
depressive disorder. Each finding may support more than one disease process.
Weight change is consistent with major depressive disorder
Level of consciousness (LOC) is consistent with alcohol toxicity.
Nausea and vomiting is consistent with alcohol toxicity
Mental status is consistent with alcohol toxicity and major depressive disorder.
Respiratory rate is consistent with alcohol toxicity.
,A nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the
potential intervention is anticipated, nonessential, or contraindicated for the client.
When addressing the client, approach them from the front when possible ANTICIPATED
Use a vest restraint to keep the client in a medical recliner. CONTRAINDICATED
Decrease sensory stimulation. ANTICIPATED
Give directions to the client slowly and in a moderate tone of voice. ANTICIPATED
Assign the client to a room near the nurses' station. ANTICIPATED
Provide the client with high-calorie protein drinks hourly. NONESSENTIAL
Ensure the bed is kept at a working height for the nurse. CONTRAINDICATED
Keep the lights off in the client's bedroom and bathroom at night. CONTAINDICATED
, A nurse is evaluating the client after 2 weeks. Which of the following findings indicate an improvement in the client's
condition? (Select all that apply.)
A nurse is caring for a client who has anorexia nervosa.
Vital Signs
Day 1:
Blood pressure 90/60 mm Hg
Heart rate 54/min
Respiratory rate 16/min
Temperature 36.1° C (97° F)
Day 14:
Blood pressure 88/58 mm Hg
Heart rate 64/min
Respiratory rate 16/min
Temperature 36.1° C (97° F)
Diagnostic Results
Day 1:
Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L)
Sodium 150 mEq/L (136 to 145 mEq/L)
BUN 35 mg/dL (10 to 20 mg/dL)
Glucose 78 mg/dL (74 to 106 mg/dL)
Day 14:
Potassium 3.7 mEq/L (3.5 to 5.0 mEq/L)
Sodium 143 mEq/L (136 to 145 mEq/L)
BUN 18 mg/dL (10 to 20 mg/dL)
Glucose 76 mg/dL (74 to 106 mg/dL)
Physical Examination
Day 1:
• BMI 16.8
• Yellow sclera
• Skin is cool
• Reports no bowel movement for 5 days
• 1+ peripheral edema
• Reports exercising 2 hr per da
contraindicated for the client.
CT scan of brain is nonessential
Monitor vital signs every 30 min is anticipated.
Obtain an Alcohol Use Disorders Identification Test (AUDIT) is nonessential.
Initiate IV access is anticipated
Administer an anti-anxiety medication is anticipated.
Wake the client every 30 min for neurological assessment is contraindicated.
For each of the client assessment findings below, click to specify if the finding is consistent with alcohol toxicity or major
depressive disorder. Each finding may support more than one disease process.
Weight change is consistent with major depressive disorder
Level of consciousness (LOC) is consistent with alcohol toxicity.
Nausea and vomiting is consistent with alcohol toxicity
Mental status is consistent with alcohol toxicity and major depressive disorder.
Respiratory rate is consistent with alcohol toxicity.
,A nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the
potential intervention is anticipated, nonessential, or contraindicated for the client.
When addressing the client, approach them from the front when possible ANTICIPATED
Use a vest restraint to keep the client in a medical recliner. CONTRAINDICATED
Decrease sensory stimulation. ANTICIPATED
Give directions to the client slowly and in a moderate tone of voice. ANTICIPATED
Assign the client to a room near the nurses' station. ANTICIPATED
Provide the client with high-calorie protein drinks hourly. NONESSENTIAL
Ensure the bed is kept at a working height for the nurse. CONTRAINDICATED
Keep the lights off in the client's bedroom and bathroom at night. CONTAINDICATED
, A nurse is evaluating the client after 2 weeks. Which of the following findings indicate an improvement in the client's
condition? (Select all that apply.)
A nurse is caring for a client who has anorexia nervosa.
Vital Signs
Day 1:
Blood pressure 90/60 mm Hg
Heart rate 54/min
Respiratory rate 16/min
Temperature 36.1° C (97° F)
Day 14:
Blood pressure 88/58 mm Hg
Heart rate 64/min
Respiratory rate 16/min
Temperature 36.1° C (97° F)
Diagnostic Results
Day 1:
Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L)
Sodium 150 mEq/L (136 to 145 mEq/L)
BUN 35 mg/dL (10 to 20 mg/dL)
Glucose 78 mg/dL (74 to 106 mg/dL)
Day 14:
Potassium 3.7 mEq/L (3.5 to 5.0 mEq/L)
Sodium 143 mEq/L (136 to 145 mEq/L)
BUN 18 mg/dL (10 to 20 mg/dL)
Glucose 76 mg/dL (74 to 106 mg/dL)
Physical Examination
Day 1:
• BMI 16.8
• Yellow sclera
• Skin is cool
• Reports no bowel movement for 5 days
• 1+ peripheral edema
• Reports exercising 2 hr per da
