1430 Nutrition, Elimination, Human Growth

Which of the following interventions would be most appropriate for a client who has urge incontinence? A) Have the client urinate on a timed schedule. B) Provide a bedside commode. C) Administer prophylactic antibiotics. D) Teach the client intermittent self-catheterization technique.

A Instructing the client to void at regularly scheduled intervals can help decrease the frequency of incontinence episodes.

A first-time mother expresses concern about how much her 12-month-old son cries when she drops him off at the child care center. Which initial action should the nurse take? A. Explain to the mother that this is an expected growth and development stage known as separation anxiety. B. Explain to the mother that this is an expected growth and development stage known as stranger anxiety. C. Report the information to the physician primary healthcare provider immediately. D. Assess the child carefully for signs of physical abuse.

A Toddlers 1-2 years old are still fearful of strangers and only want who is familiar to them. Separation anxiety may be expected.

Patient teaching for tamsulosin:

-Take dose 30 mins following the same meal every day. If dose is missed, skip it and return to normal dosing schedule -May cause headache and orthostatic hypotension. Use caution when performing any hazardous task -Do not discontinue or skip without contacting physician

The nurse is caring for a 3-year-old child with iron deficiency anemia and providing dietary instructions to the parents. Which of the following should be a priority for the nurse to include in the teaching? A. recommending lean meats B. take a multivitamin C. drink 8oz glass of water with iron supplement D. increase fiber in diet

A From the list, meat is the food source with the highest iron content.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Vegetable juice 6. Pureed vegetables

1, 2, 3 Clear liquids include jello, popsicles, coffee, fruit juice, etc.

A client with GERD is to receive metoclopramide 15mg/mL orally before meals. The concentration solution contains 10mg/mL. How much solution will the nurse administer?

1.5mL

The nurse in a long-term care facility is teaching a group of residents about increasing dietary fiber. Which foods should she explain are high in fiber? 1) White bread, pasta, and white rice 2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice and bananas

2 Rationale: Oranges, raisins, and strawberries are high in fiber. What are the other answer choices examples of?

A client who is recovering from a surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been bored with the clear liquid diet. The nurse should offer which full liquid item to the client? 1. Tea 2. Gelatin 3. Custard 4. Ice pop

3 All of the other answer choices are in what kind of diet?

A client with the urge incontinence is receiving oxybutynin 30 mg orally. Each tablet contains 5 mg. How many tablets should the nurse administer?

6 tabs

What should the nurse teach the client to do to prevent stress incontinence? Select all that apply. A) Use techniques that strengthen the sphincter and structural supports of the bladder, such as Kegel exercises. B) Limit dietary irritants (e.g., caffeine, alcoholic beverages). C) Not to laugh when in social gatherings. D) Carry an extra incontinence pad when away from home E) Obtain a fluid intake of 500 mL/ day.

A, B Laughing may be a part of one's socialization, so it should not be discouraged. In non-restricted clients, a fluid intake of at least 2 to 3 L/ day is encouraged; clients with stress incontinence may reduce their fluid intake to avoid incontinence at the risk of developing dehydration and urinary tract infections. Establishing a voiding schedule would be more effective in the prevention of stress incontinence rather than carrying incontinence pads. Dietary irritants and natural diuretics, such as caffeine and alcoholic beverages, may increase stress incontinence. Kegel exercises strengthen the sphincter and structural supports of the bladder.

Ferrous gluconate should be _________________. A. Taken on an empty stomach B. Taken with tea or coffee C. Taken with an antacid D. Taken with grapefruit juice E. Drank with a straw to avoid staining teeth

A, E On an empty stomach! With NO coffee or tea. Drink with a straw because this may cause temporary staining of teeth.

A patient with acute urinary retention associated with BPH is admitted to the emergency department. The patient has had no urine output for 16 hours, and the laboratory work shows a blood urea nitrogen (BUN) level of 50 mg/dl and a creatinine of 3.0 mg/dl. The nurse will anticipate a health care provider order to a. schedule the patient for inpatient hemodialysis.' b. insert a retention catheter. c. start an IV line for fluid administration. d. administer furosemide (Lasix).

Answer: B Rationale: The patient data indicate that the patient may have acute renal failure caused by the BPH; the initial therapy will be to insert a catheter. Hemodialysis may be needed if the elevation in BUN and creatinine persists, but it will not be ordered initially. Fluid administration and furosemide administration will increase the bladder distension.

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. the presence of blood in the urine b. any erectile dysfunction (ED). c. occurrence of a weak urinary stream. d. lower back and hip pain.

Answer: C Rationale: The American Urological Association (AUA) Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and back or hip pain are not typical symptoms with BPH.

The nurse is caring for the client diagnosed with Colstridium difficile. Which intervention should the nurse implement to prevent health-case associated infection spread to other clients? A. Wash hands with Betadine for 2 minutes after giving care. B. Wear nonsterile gloves when handling GI excretions. C. Clean the perianal area with soap and water after each stool. D. Flush the commode twice when disposing of stool.

B Clean gloves should be work when providing care to prevent the transfer of the bacteria found in the stool. This will prevent the spread of bacteria to other clients in the health-care facility. But this is not a substitute for good hygiene. The nurse should clean the perianal area or instruct the client to clean the area but this will not prevent the spread of bacteria. Betadine is not the best cleaning solution. Soap and water for 15-30 seconds while washing hands before and after caring for the client.

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? A. Cheeseburger and french fries B. Chicken and orange slices C. Gelatin salad and tea D. Cheese omelet and bacon

B Protein and vitamin C are particularly important in promoting wound healing and recovery from infection. A diet high in carbohydrates is also essential. Because the client with an infection commonly does not feel like eating, it is important that what the client eats should be nutritious. Chicken and orange slices would help meet the client's protein and vitamin needs. A meal of cheeseburger and fries or cheese omelet and bacon is high in fat and do not contain as much vitamin C as the chicken and orange slices. Gelatin salad and tea contain minimal nutrients.

A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include? A. Fat breaks down into amino acids B. Protein serves as an energy source when other sources are inadequate C. Glucose breaks down into ammonia D. Carbohydrates provide 9 cal/g of energy

B Protein is used as an energy source for the body when carbs and fat stores are unavailable and depleted. Protein breaks down into amino acids. Protein breaks down into ammonia. Carbs provide 4 cal/g of energy. Fat provides 9 cal/g of energy.

A client with iron deficiency anemia is taking iron supplements. What nutrient should the nurse instruct the client to take the supplements with in order to increase the absorption of iron? A. beta-carodene B. orange juice C. food D. milk

B Vitamin C helps promote absorption of iron

What statement by an older adult most strongly supports the conclusion that the client is impacted with stool? A. "I have a lot of as pains" B. "I don't have much of an appetite." C. "I feel like I have to go and just can't" D. "I haven't had a bowel movement for several days."

C A client with a fecal impaction has the urge to defecate but is unable to do so.

A client with cancer of the prostate requests the urinal at frequent intervals but either does not void or voids in very small amounts. What does the nurse conclude is most likely the causative factor? A. Edema B. Dysuria C. Retention D. Suppression

C An enlarged prostate constricts the urethra, interfering with the flow of urine and causing retention. When the bladder fills and approaches capacity, small amounts can be voided, but the bladder never empties completely. Dysuria is painful or difficult urination which is not part of the clients response.

A nurse is providing teaching about nutrition diets to a group of adult women. Which of the following statements should the nurse include? A. "Include at least 3 g of sodium in your daily diet." B. "Limit wine consumption to 230mL daily." C. "Include 2.5 cups of vegetables in your daily diet." D. "Limit water intake to 1.5L each day."

C Nutritious diets contain a variety of foods to ensure the required daily allowance of nutrients is ingested. The nurse should instruct the women to include 2.5 cups of vegetables and 2 cups of fruit in their daily diets. Fruits and veggies should be variety of colors to provide an assortment of nutrients. A is wrong because the nurse should teach to consume sodium in moderation. The American Heart Association recommends consuming less than 2.5g of Na daily and the adequate sodium intake is 1.5g. Excessive Na can lead to HTN.

The clinic nurse is talking on the phone to a client with diarrhea. Which intervention should the nurse discuss with the client? A. Tell the client to measure amount of stool. B. Recommend the client come to the clinic immediately. C. Explain the client should follow the BRAT (bananas, rice applesauce, and toast) diet. D. Discuss taking an OTC histamine 2-blocker.

C The BRAT dies is recommended for a client diagnosed with diarrhea because it is low residue and produces nutrition while not irritating the GI system. It is not B because unless the client has had diarrhea for longer than 48 hours, the client does not need to be seen in the clinic. The clinic nurse should not ask the client to measure stool at home; this is done in the acute care setting.

The nurse is caring for a patient whose BMI is 32. Based on this assessment finding, what should the nurse do first? A. Refer the patient to a dietician so that a meal plan can be created B. Notify the practitioner so that a cholesterol-lowering medication can be started C. Assess the patient's dietary intake, using a 24-hour food recall D. Reassess the patient's BMI in 6 months

C The first action would be to assess the patients diet to determine what the patients normal dietary intake is so that he can receive the proper education.

Which nursing intervention is most developmentally appropriate for a hospitalized 10 year old? a. Encourage the child to play with safe medical equipment. b. Encourage dependency on the child's parents while the child is hospitalized. c. Allow the child to assist with dressing changes. d. Obtain a complete health history from the child.

C This is an appropriate intervention for a child of this age group. School age children around 6-12 fear a loss of control, so it is important to allow them to be involved in their care as appropriate.

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse to take first? A. Refer the client to a nutritionist B. Discuss eating strategies with the client C. Determine the client's intention to change current eating habits D. Instruct the client to perform vigorous exercise daily

C When using the nursing process, the nurse should first asses the client's readiness to commit to a change behavior.

A patient is admitted with iron- deficiency anemia and has been receiving iron supplementation. The patient voices concern about how their stool is dark black. As the nurse, you would? A. Notify the doctor B. Hold the next dose of iron C. Reassure the patient this is a normal side effect of iron supplementation D. None of the options are correct

C An expected side effect of ferrous sulfate is black, tarry stools.

The RN, an LPN, and a UAP are caring for clients on a medical floor. Which nursing task would be most appropriate to assign the LPN? A. Assign the UAP to learn to perform blood glucose checks. B. Monitor the potassium levels of a client diagnosed with diarrhea. C. Administer a bulk laxative to a client diagnosed with constipation. D. Assess the abdomen of a client reporting abdominal pain.

C The LPN can administer medications such as laxatives. The RN will be responsible for signing off on the UAP when competent to perform blood glucose checks. The lab values of potassium may require the nurse to interpret and act on the results. The nurse cannot delegate assessments of what could potentially be critical patients.

A client has impaired skin integrity related to compromised circulation. What should the nurse include in the teaching plan regarding nutritional considerations? A. Adherence to a diet that helps with weight reduction B. Elimination of carbohydrates and fats from the diet C. Supplementation of diet with vitamins and antioxidants D. Adequate intake of vitamins A and C, protein, and zinc

D For clients with a risk for impaired skin integrity related to compromised circulation, good nutrition in the form of adequate intake of vitamins A and C, protein, and zinc is recommended. Only clients who are overweight or obese need a diet that helps with weight reduction. Research does not support that supplementation with vitamins and antioxidants prevents vascular disease. There is no need to eliminate carbohydrates and fats from someone's diet.

A client is admitted to the hospital with a BMI of 30.2. What should the nurse document in the client's EHR A. Underweight B. Overweight C. Ideal weight D. Obese

D This client is obese, with a BMI greater than 30. A client with less than 18.5 BMI is underweight. A BMI between 25-29.9 is considered underweight. The ideal weight for a client is a BMI between 18.5 and 24.9

When a 12 year old child is prescribed methylphenidate, which is most important for the nurse to monitor? A: Temperature B: Respirations C: Intake and output D: Height and weight

D Why is it important to monitor height and especially weight at every doctors visit?

True or False A patient diagnosed with malnutrition will always have a thin appearance.

False! Y'all better know this!

Calculate the total intake in mL for the following situation: TPN infusion 850 mL left in 1460 mL TPN IV bag Jejunostomy tube output 310 mL Foley catheter output 380 mL

Intake = 610 mL

Calculate the total fluid output in mL for the following situation: Ileostomy output 410 mL Hemovac wound drainage 12 oz Foley catheter ouput 625 mL

Output = 1395mL