EAQ #1 Health and Illness
When teaching an adolescent with type 1 diabetes about dietary management, which instruction would the nurse include? Meals should be eaten at home. Foods should be weighed on a gram scale. A ready source of glucose should be available. Specific foods should be cooked for the adolescent.
An adolescent with type 1 diabetes must carry a source of simple sugar (e.g., glucose tablets, Insta-Glucose, sugar-containing candy such as LifeSavers) to rapidly counteract the effects of hypoglycemia. This should be followed by a complex carbohydrate and a protein. Stating that meals should be eaten at home is an unrealistic and unnatural instruction for an adolescent. Stating that foods should be weighed on a gram scale is an unnecessary and time-consuming procedure. The adolescent should be made to feel a part of the family; the recommended diet is nutritious and no different from that of the rest of the family.
The nurse assesses a client's intravenous (IV) site. Which clinical finding leads the nurse to conclude that the IV has infiltrated, rather than caused inflammation? Pain Coolness Localized swelling Cessation in flow of solution
When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approximately 75°F [23.9°C]), whereas body temperature is approximately 98.6°F (37°C); therefore the client's skin will feel cool to the touch at the site of an IV infiltration. The site of an inflammation will feel warm to the touch because of vasodilation and hyperemia. Pain may occur with both an inflammation and an infiltration. The pain of an inflammation is related to the pressure of edema on nerve endings. The pain of an infiltration is related to the IV solution in the interstitial compartment pressing on nerve endings. An increase in interstitial fluid occurs with both an inflammation and an infiltration. With an inflammation there is increased vascular permeability at the site; fluid, proteins, and leukocytes then move from the intravascular compartment into the interstitial compartment. With an infiltration the IV solution enters the interstitial compartment rather than the intravascular compartment. A cessation in flow of solution occurs with both an inflammation and an infiltration. An inflammation in the vein at the insertion site may narrow the lumen of the vessel, interfering with the flow of solution. An infiltration will cause excess fluid in the interstitial compartment to the extent that it will not accommodate more solution, interfering with the flow of the solution.
Which is the action of an antidiuretic hormone (ADH)? Reduces blood volume Decreases water loss in urine Increases urine output Initiates the thirst mechanism
ADH is released by the posterior pituitary gland. It is released mainly in response to either a decrease in blood volume or an increased concentration of sodium or other substances in the plasma. It acts to decrease the production of urine by increasing the reabsorption of water by renal tubules. A decrease in ADH would cause reduced blood fluid volume; decreased ability of the kidneys to reabsorb water, resulting in increased urine output; and an increase in the thirst mechanism.
Which hormone aids in regulating intestinal calcium and phosphorus absorption? Insulin Throxine Glucocorticoids Parathyroid hormone
Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.
The nurse finds that an adolescent has episodes of binge eating followed by self-induced vomiting and strenuous exercise. Which condition is the adolescent likely to have? Bulimia Anorexia Orthorexia Binge behavior
Bulimia is a disorder characterized by repeated episodes of binge eating followed by inappropriate compensatory behavior, such as self-induced vomiting and/or strenuous exercise. Anorexia is an eating disorder characterized by low body weight. Orthorexia is a disorder in which the individual avoids certain foods, believing them to be harmful. Binge behavior is consumption of large amounts of foods in a brief time but without the subsequent compensatory behavior.
While awaiting surgery, a client with a history of Crohn disease is receiving total parenteral nutrition (TPN) on an outpatient basis. The nurse teaches the client that TPN helps prepare for surgery by which process? Decreasing fecal bulk Preventing bowel infection Providing stimulation of secretions Maintaining negative nitrogen balance
By decreasing fecal bulk and bowel stimulation, TPN provides rest for the bowel while the client awaits surgery. TPN does not prevent a bowel infection. TPN does not stimulate gastrointestinal secretions. TPN promotes positive nitrogen balance.
Which medication is derived from a natural source and may be prescribed for the treatment of osteoporosis? Calcitonin Raloxifene Clomiphene Bisphosphonates
Calcitonin is derived from natural sources such as fish; this medication may be prescribed to prevent osteoporosis. Raloxifene is prescribed to prevent postmenopausal osteoporosis. Clomiphene is prescribed to induce ovulation. Bisphosphonates are prescribed to treat osteoporosis; this medication is not derived from natural sources.
Which would be treatment goals in anorexia nervosa? Select all that apply. One, some, or all responses may be correct. The development of a calorie-restricted diet plan The development of a regular exercise schedule The repairing of family interactions The reinstitution of normal nutrition to counteract a state of malnutrition The correction of deficits and distortions in psychological functioning via psychotherapy
Clients with anorexia nervosa have a strong fear of becoming overweight. This is characterized by reduced nutritional food intake, causing progressive weight loss and malnutrition. These clients usually have impaired family interactions due to low self-esteem. The treatment goals should consist of repairing family interactions, reinstituting normal nutritional meals, and correcting deficits and distortions in psychological functioning.
The nurse is teaching a class about nutrition to a group of adolescents. Taking into consideration the prevalence of overweight teenagers, which is the best recommendation? 'Join a gym.' 'Drink fewer diet sodas.' 'Decrease fast-food intake.' 'Take a multivitamin daily.'
Eating a variety of healthful foods instead of a fast-food diet that is high in fat and carbohydrates helps decrease excess weight and increase energy with which to engage in physical activities. Joining a gym is expensive and unnecessary. Physical activity can be achieved in the schoolyard or at home. A multivitamin will not promote weight loss. Vitamins and minerals are best obtained in a balanced diet. Diet soft drinks do not contribute to obesity.
When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers? Avoid massaging the client's legs. Frequently reposition the client on a scheduled basis. Increase the fiber content in the client's food. Encourage the client to participate in weight-bearing exercises.
Frequent repositioning of the client in bed or wheelchair on a scheduled basis will relieve pressure points, thereby decreasing potential development of pressure ulcers. Avoiding leg massages will decrease the risk of embolism, but does not prevent pressure ulcers. Increased intake of dietary fiber will relieve the immobilized client of constipation. Weight-bearing exercises will prevent the immobilized client from developing muscular atrophy or loss of calcium from the bone.
In which category of fluids would the nurse classify an intravenous solution of 0.45% sodium chloride? Isotonic Isomeric Hypotonic Hypertonic
Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure because their concentration is equivalent to that of body fluid. This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.
The nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client. Which is the volume of solution that would be prepared? 150 to 250 mL 250 to 350 mL 300 to 500 mL 500 to 750 mL
In adolescents, the volume of solution required is 500 to 750 mL. The nurse would prepare 150 to 250 mL of warmed solution for infants. The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.
The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feedings at home. Which client statement indicates effective teaching? 'Before I start the procedure, I will don sterile gloves.' 'Before I start the procedure, I will obtain my body weight.' 'Before I start the procedure, I will measure the residual volume.' 'Before I start the procedure, I will instill 1 oz [30 mL] of a carbonated liquid.'
Measuring the residual volume establishes the absorption amount of the previous feeding. If a residual exceeds the parameter identified by the health care provider or is over 200 mL, a feeding may be held. This safety measure prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. The client obtains and reports weekly or monthly weights, depending on the client's condition and clinical goals. If the tube becomes clogged, the client may instill 30 mL of a carbonated beverage; this action is not used routinely.
Which statement regarding the teenage diet is true? Adolescents are fond of healthy food. Adolescents need vitamin supplements. Adolescents need high amounts of calories. Adolescents require low amounts of protein.
The energy needs of teenagers increase to meet the greater metabolic demands of growth. Adolescents are fond of eating fast food at restaurants. Vitamin supplements are not required for teenagers. The daily requirement of protein increases in teenagers.
A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action will the nurse take next? Send another blood sample to the laboratory to retest the serum potassium level. Notify the health care provider that the potassium level is above normal. Notify the health care provider that the potassium level is below normal. No action is required because the potassium level is within normal limits.
The health care provider should be notified immediately because the client's potassium is below normal. The normal potassium level range is 3.5 mEq/L to 5.0 mEq/L (3.5-5.0 mmol/L). Clients on diuretic therapy require close monitoring of their electrolytes because some can cause hypokalemia, whereas others spare potassium, which can cause hyperkalemia. Retesting the serum potassium level is unnecessary and will delay the treatment required by the client.
Which cation regulates intracellular osmolarity? Sodium Potassium Calcium Calcitonin
A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.
The health care provider prescribes a blood transfusion for a client with esophageal varices. Place the following nursing actions in the correct order. 1. Check the client's vital signs. 2. Establish intravenous (IV) access with IV normal saline. 3. Verify the blood product with another nurse against the client's identification (ID) bracelet. 4. Monitor the client's vital signs and status according to agency policy.
Baseline vital signs should be obtained immediately before administering the blood product for future comparison purposes. Before obtaining the blood, it is important to have IV access because if there is difficulty establishing an IV after blood is obtained, the blood cannot be returned to the blood bank. Two licensed nurses would confirm the verifying data between the client and the blood product. The nurse would remain with and monitor the client's vital signs during the first 15 minutes of administration of the blood product and then follow the institution's protocol to monitor for a transfusion reaction or fluid overload.
Which is the reason for calculating a body mass index (BMI)-for-age during a health maintenance assessment for school-age clients? Assessing for bulimia nervosa Monitoring for failure to thrive Monitoring for anorexia nervosa Assessing for obesity or overweight
Because of the increasing number of overweight children in the United States, the BMI charts are a critical component of children's physical assessment. BMI-for-age may be used to identify children and adolescents at the upper end of the distribution who are either overweight (at or above 95th percentile) or at risk for being overweight (at or above the 85th percentile and below the 95th percentile). Assessing for bulimia nervosa and anorexia nervosa is more appropriate for an adolescent versus a school-age child. Assessing for failure to thrive (FTT) is more appropriate for the infant, toddler, and preschool-age child.
An adolescent was recently diagnosed with type 2 diabetes mellitus. Which information will the nurse include when providing education to the family? 'Your teen will need insulin injections for the rest of her life.' 'The most important interventions are good nutrition and portion control.' 'This is a condition where the body produces antibodies against its own cells.' 'This condition causes weight loss and increased appetite, thirst, and urination.'
Most children with type 2 diabetes are overweight or at risk for becoming overweight. With nutritional intervention to promote proper weight, the condition may often be managed with diet and exercise alone. A lifelong insulin regimen, the production of antibodies against the child's own cells, and weight loss with increased appetite, thirst, and urination are all typical of type 1 diabetes.
Which nutrients would the nurse teach the parents of a child with celiac disease to avoid? Saturated oils and fats Milk and hard cheeses Corn and rice products Wheat and oat products
Wheat, oats, rye, and barley are major dietary sources of gluten; the gliadin fraction of these grains is not tolerated by individuals with celiac disease. There is no gluten in oils and fats. There is no gluten in cheeses and milk. Corn and rice are used as substitute grains because they do not contain gluten.
