NURS 13A Topic 5 Digestion & Nutrition PrepU
An older adult client, who states recently starting herbal therapy for weight loss, reports losing weight and a decrease in appetite. Which assessment(s) will the nurse use to confirm the client's progress? Select all that apply. A. review of food journal B. client statements C. weight D. physical measurements E. spouse's outline of meal plan
A, B, C Explanation: The nurse will assess the client's weight and physical measurements, as well as review the client's food journal. The nurse will not accept the statements of the client and spouse as confirmation.
An older adult client asks about natural means to promote bowel elimination. What should the nurse encourage the client to incorporate into a daily routine? Select all that apply. A. A variety of vegetables B. Increased fruit intake C. Increased fluid intake D. Organic foods E. Regular physical activity
A, B, C, E Explanation: Fluid, fruits, vegetables, and activity are important to incorporate into a daily routine to promote bowel elimination. Foods do not need to be organic to enhance bowel function.
An older adult client is diagnosed with esophageal cancer. Which treatment(s) should the nurse expect to be prescribed for this client? Select all that apply. A. Laser therapy B. Esophagoscopy C. Surgical resection D. Chemotherapy E. Radiation
A, C, D, E Explanation: Treatment options for esophageal cancer include radiation, laser therapy, chemotherapy, and surgical resection. Esophagoscopy is performed as a diagnostic measure.
A 60-year-old client asks why it is so easy to gain weight but difficult to lose. How should the nurse respond to this client? A. "Basal metabolic rate declines by 2% for each decade of life after age 25." B. "Metabolism of carbohydrates changes with aging." C. "It is because muscle tissue is greater than adipose tissue in the aging body." D. "Weight gain occurs when insufficient amounts of protein are ingested."
A. "Basal metabolic rate declines by 2% for each decade of life after age 25." Explanation: Basal metabolic rate declines 2% for each decade of life after age 25, which contributes to weight increase when the same caloric intake of younger years is consumed. The metabolism of nutrients does not change with aging. Insufficient amounts of ingested protein do not cause weight gain. The older body has less lean body mass and an increase in adipose tissue.
An older adult client is concerned about bleeding gums when brushing the teeth. What should the nurse respond to this client? (repeated 1x) A. "It could mean you have the beginning of periodontal disease." B. "Increase your intake of green vegetables to help stop the bleeding." C. "Bleeding means you are taking too much aspirin." D. "That is nothing to worry about. Everyone's gums bleed at times."
A. "It could mean you have the beginning of periodontal disease." Explanation: One sign of periodontal disease is bleeding gums with toothbrushing. Other than possible periodontal disease, the nurse has no way of knowing why the client's gums bleed. Everyone's gums do not bleed. Suggesting the client eat more green vegetables is an attempt to increase the level of vitamin K, a natural blood clotting vitamin. Depending upon the client's health status, this could be contraindicated.
An older adult reports that the dentures are rubbing against the gums and causing discomfort. The client is not wearing the dentures at all now and states it will be too expensive to buy another set. What is the nurse's best response? (repeated 1x) A. "Sometimes dentures can be lined to ensure a proper fit." B. "You should eat soups and soft foods since you are not able to chew." C. "Not wearing your dentures poses a choking hazard." D. "You should clean your dentures thoroughly to help them fit better."
A. "Sometimes dentures can be lined to ensure a proper fit." Explanation: Poorly fitting dentures need not always be replaced; sometimes they can be lined to ensure a proper fit. Eating soft foods is important, but this response does not address the financial concern of replacing the dentures and is not the best solution for the long term due to possible nutrient deficiencies of a soft food and liquid diet. Wearing ill-fitting dentures is an aspiration risk. The client should clean the dentures, but this does not help the fit.
An older adult client reports often experiencing "indigestion" after eating fatty foods. The client states that this never used to happen when younger and asks the nurse why this is now the case. How will the nurse respond? (repeated 1x) A. "With age, reduced pancreatic secretions can affect the digestion of fatty foods." B. "With age, increased salivary secretions can affect the digestion of fatty foods." C. "With age, decreased liver secretions can affect the digestion of fatty foods." D. "With age, increased pancreatic secretions can affect the digestion of fatty foods."
A. "With age, reduced pancreatic secretions can affect the digestion of fatty foods." Explanation: With age, reduced pancreatic secretions can affect the digestion of fatty foods. With age, pancreatic secretions are reduced (not increased), salivation is decreased, and the liver size decreases (although liver function should remain within normal limits).
A frail older adult client who has slowly been losing weight states, "I just feel so full so full, I cannot eat any more." Which initial recommendation will the nurse make? A. Eat five small meals during the day. B. Make an appointment with your health care provider. C. Increase exercise. D. Restrict fluids during meals.
A. Eat five small meals during the day. Explanation: Slight slowing of gastric emptying in older adults after ingestion of large meals leads to early sensations of fullness. The nurse will recommend the client eat 5 small meals throughout the day. Restriction of fluid or increase in exercise will not resolve this issue. Making an appointment with the health care provider is not an initial intervention the nurse would recommend the client use to improve the problem.
During a physical examination the nurse notes flaccid skin around the entrance to an older adult client's anus. What should the nurse suspect is occurring with this client? (Repeated 2x) A. Hemorrhoids B. Rectal tumor C. Anal infection D. Rectal fissure
A. Hemorrhoids Explanation: Flaccid skin around the entrance to the anus are hemorrhoids. This tissue is not a rectal tumor. A rectal fissure is not visible when inspecting the anus. The flaccid tissue is not caused by an infection.
An older adult client has just completed eating breakfast. What action will the nurse take before beginning morning hygiene care? A. Offer the bed pan. B. Assist with dressing. C. Ambulate down the hall. D. Assist to sit in a chair.
A. Offer the bed pan Explanation: It is useful for an older adult client to attempt a bowel movement following breakfast, because the morning activity and ingestion of food and fluid following a period of rest stimulates peristalsis. Assisting the client with dressing occurs after morning hygiene care. There is no reason to assist the client to sit in a chair at this time. Ambulation can occur later if appropriate for the client's health status.
An older adult client reports heart palpitations and claims eating rhubarb daily. Which laboratory results should the nurse review? (Repeated 2x) A. Potassium B. Magnesium C. Calcium D. Sodium
A. Potassium Explanation: An adverse effect of excessive rhubarb is hypokalemia, which causes disturbances in cardiac function. The nurse should assess the potassium level. Rhubarb does not normally affect sodium, magnesium or calcium levels.
An older adult client experiences heartburn, belching, and regurgitation. Which diagnostic test should the nurse anticipate being prescribed for this client? A. barium swallow B. liver-spleen scan C. computed tomography (CT) scan of the thorax D. magnetic resonance imaging (MRI) of the chest
A. barium swallowing Explanation: The client is demonstrating signs of a hiatal hernia. A barium swallow is used to diagnose this disorder. An MRI of the chest, liver-spleen scan, and CT scan of the thorax are not used to diagnose a hiatal hernia.
An older adult client is admitted to a nursing unit with the above laboratory results. Which client concern is priority? Sodium: 154 mEq/l (154 mmol/l) Blood urea nitrogen: 27 mg/dl (9.64 mmol/l) Hematocrit: 56% (0.56) Albumin: 6.2 g/dl (62g/l) A. fluid volume deficit B. constipation C. malnutrition D. impaired tissue perfusion
A. fluid volume deficit Explanation: The appropriate concern is fluid volume deficit. In dehydration, blood values, which may be altered, include elevations in sodium, hematocrit, creatinine, osmolality, and blood urea nitrogen. While the client may develop constipation, it is not the priority at this time. Albumin becomes diminished with poor nutrition but increased with dehydration. An elevation in these laboratory values does not implicate impaired tissue perfusion.
The nurse is assessing a client's gastrointestinal system. Which approach should the nurse use to determine the status of the client's vagus nerve? A. press a tongue depressor on the tongue and have the client say "ah" B. examine the tongue for color and landscape C. ask the client to stick out the tongue D. observe neck movement while asking the client to swallow
A. press a tongue depressor on the tongue and have the client say "ah" Explanation: During normal swallowing, the vagus nerve causes the soft palate to rise and block the nasopharynx so that aspiration is prevented. To test this function, the nurse presses a tongue depressor on the middle of the tongue and ask the client to say "ah." The soft palate should rise when "ah" is said. Sticking out the tongue, examining the tongue, and observing neck movement while swallowing do not assess the status of the vagus nerve.
An adult child caring for an older adult parent calls the nurse, stating concern about the parent's chronic bad breath and stubborn plaque on the teeth. Which teeth-cleaning measure should the nurse recommend for this older adult? A. "An alcohol-based mouthwash will kill bacteria causing the odor." B. "An manual toothbrush is most effective when giving oral hygiene." C. "Use a soft swab to clean the teeth as well as gums." D. "Lemon-glycerin swabs should be used to clean around the gumline."
B. "An manual toothbrush is most effective when giving oral hygiene." Explanation: The use of a toothbrush is more effective than swabs or other soft devices in improving gingival tissues and removing soft debris from the teeth. Lemon-glycerin swabs dry the oral mucosa and contribute to tooth enamel erosion. Mouthwashes with high alcohol content can be too harsh for the mouths of older adults.
A 60-year-old client asks why it is so easy to gain weight but difficult to lose. How should the nurse respond to this client? A. "It is because muscle tissue is greater than adipose tissue in the aging body." B. "Basal metabolic rate declines by 2% for each decade of life after age 25." C. "Weight gain occurs when insufficient amounts of protein are ingested." D. "Metabolism of carbohydrates changes with aging."
B. "Basal metabolic rate declines by 2% for each decade of life after age 25." Explanation: Basal metabolic rate declines 2% for each decade of life after age 25, which contributes to weight increase when the same caloric intake of younger years is consumed. The metabolism of nutrients does not change with aging. Insufficient amounts of ingested protein do not cause weight gain. The older body has less lean body mass and an increase in adipose tissue.
The nurse instructs a client with a hiatal hernia. Which statement indicates that teaching has been effective? A. "I should have a high-protein snack at bedtime." B. "I need to stop drinking coffee." C. "I should lay down for 1 hour after eating." D. "I should eat two meals a day."
B. "I need to stop drinking coffee." Explanation: The client should be discouraged from consuming caffeinated beverages. The client should be instructed to eat five to six small meals during the day. The client should be instructed to sit upright for at least 1 hour after eating. The client should be advised to avoid eating for at least 2 hours before bedtime.
An older adult client asks if it is "normal" to have to move the bowels twice within the same hour. What should the nurse respond to this client? A. "This is caused by your medications." B. "This is a normal age-related change." C. "It happens to people who do not drink enough fluid." D. "This means you are constipated."
B. "This is a normal age-related change." Explanation: There is a tendency for older adults to not empty the bowel with one movement. Thirty to 45 minutes after the initial movement, the remainder of the bowel movement may need to occur. Having to move the bowels more than once in an hour does not indicate constipation. This is not caused by medication and does not occur in individuals who are fluid volume depleted.
An older adult client occasionally experiences fecal incontinence. Which action should the nurse take first when determining the reason for the client's incontinence? (Repeated 2x) A. Restrict fluids. B. Assess for an impaction. C. Increase dietary fiber. D. Administer an enema.press a tongue depressor on the tongue and have the client say "ah" examine the tongue for color and landscape ask the client to stick out the tongue observe neck movement while asking the client to swallow
B. Assess for an impaction. Explanation: Fecal incontinence is most often associated with fecal impaction. For this reason, the initial step is to assess for the presence of an impaction. Restricting fluids, performing an enema, and increasing dietary fiber will not assist the nurse to determine the reason for a client experiencing fecal incontinence.
The nurse reviews the vitamin supplements that an older adult client takes daily. Which supplement should the nurse recommend that the client alter the dosage? A. Zinc 8 mg B. Calcium 1200 mg (if calcium is used, no more than 500mg at a time) C. Vitamin D 400 Units D. Vitamin C 75 mg
B. Calcium 1200 mg Explanation: If calcium supplements are used, no more than 500 mg should be taken at any one time because larger amounts are not absorbed as well. The nurse should counsel the client to change the number of milligrams of calcium in each supplement pill. The doses of zinc, vitamin C, and vitamin D are all within the recommended daily intake amounts.
An older adult male client who consumes an excessive amount of calcium reports lower, right-sided abdominal pain. What should be the nurse's first action after completing a pain assessment? (repeated 1x) A. Administer analgesia as prescribed. B. Collect a urine specimen. C. Request a bone density scan. D. Ask the care provider to order a chest x-ray.
B. Collect a urine specimen. Explanation: Excess calcium consumption can lead to problems such as kidney stones. Therefore, with the client's history of excessive calcium intake, a urine specimen should be collected to assess for signs of kidney stones. There is no indication for a chest x-ray or a bone density scan. Pain medication may be prescribed after assessing for kidney stones.
An older adult client asks what can be done to enhance sleep and eliminate a nagging headache that comes on toward the end of the day. Which herb should the nurse suggest that the client limit the intake? A. Echinacea B. Green tea C. Cayenne D. Aloe
B. Green tea Explanation: Green tea can cause insomnia and headaches. Aloe can cause arrhythmias and edema. Cayenne can cause gastrointestinal discomfort and liver damage. Echinacea can cause fevers.
Which of the following points should a nurse stress in a health education class for older adults about constipation? (Repeated 2x) A. Older adults should limit their intake of high-fiber foods because of a risk of lactose intolerance. B. If older adults need a medication to promote bowel regularity, a bulk-forming agent is needed daily. C. If older adults need a medication to promote bowel regularity, a laxative or enema should be given. D. Older adults who do not have a daily bowel movement should use a laxative.
B. If older adults need a medication to promote bowel regularity, a bulk-forming agent is needed daily. Explanation: A bulk-forming agent is least likely to have detrimental effects if a medication is needed to promote regular bowel elimination. If at all possible, older adults should avoid laxatives. Older adults should include several portions of high-fiber foods in their daily diet.
An older client presents with decreased skin turgor; a brown, dry tongue; sunken cheeks; concentrated urine; and a blood urea value of 70 mg/dL (25 mmol/L). Based on these findings, the nurse should also assess for which priority finding? (Repeated 2x) A. Elevated white blood cell count B. Sodium and potassium imbalances C. Increased bladder distensibility D. Constipation
B. Sodium and potassium imbalances Explanation: This client's presentation is consistent with a dehydration. Fluid and electrolyte imbalances are priority complications to assess for when an older client is diagnosed with dehydration. While constipation and infection are concerns, an elevated white blood cell count is not as life threatening as an electrolyte imbalance, especially potassium. Electrolyte imbalances can affect the heart and are priority concerns. Decreased bladder distensibility occurs with dehydration, not increased distensibility.
The nurse is concerned that an older adult female client is at risk for developing breast cancer. What assessment finding caused the nurse to have this concern? A. eats approximately 1 teaspoon of fat each day B. ingests three 12-ounce (355 ml) cans of beer each evening C. drinks 2 cups of coffee each day D. body mass index 27.5
B. ingests three 12-ounce (355 ml) cans of beer each evening Explanation: The daily intake of 40 grams or more of alcohol has been linked to an increased risk for breast cancer. Given that an average 12-ounce (355-ml) can of beer (5% ABV) has 14 grams of alcohol, the client is at a higher risk for developing breast cancer. Being overweight can contribute to heart disease and osteoporosis. Caffeine increases the risk for osteoporosis. Limiting fat intake helps prevent the development of heart disease and breast cancer.
A client's blood calcium level remains low despite taking the prescribed amount of calcium supplement each day. For which other nutrient should the nurse assess if this client is ingesting? (repeated 1x) A. zinc B. magnesium C. potassium D. vitamin B
B. magnesium Explanation: A good intake of vitamin D and magnesium facilitates calcium absorption. Zinc helps with wound healing. Vitamin B helps with metabolic and nervous system processes. Potassium helps regular blood pressure.
The long-term care nurse is assessing the nutritional status of a group of clients. Which client(s) does the nurse determine as being at risk for impaired gustatory function? Select all that apply. A. The client with a 10-year history of diabetes mellitus. B. The client with poorly controlled hyperthyroidism. C. The client who has recently completed radiation therapy. D. The client with a history of head trauma. E. The client with rapidly progressing Alzheimer disease.
C, D, E Explanation: The clients who underwent radiation therapy, with rapidly progressing Alzheimer disease, and with a history of head trauma respectively are at risk for impaired gustatory function, which is defined as an impaired ability to taste. A 10-year history of diabetes mellitus and poorly controlled hyperthyroidism are not common conditions associated with impaired gustatory function.
At a health fair, the nurse assesses an older adult client and calculates a body mass index (BMI) of 15. Which response by the nurse is appropriate? A. "Have you been underweight all your life?" B. "Have you tried to lose weight?" C. "Have you been losing weight without trying?" D. "Congratulations your BMI is great."
C. "Have you been losing weight without trying?" Explanation: The nurse uses therapeutic communication to assess the weight loss. Unintentional weight loss is a significant indicator of poor nutrition. A healthy adult body mass index (BMI) is between 18 and 25 and may extend to 30 for older adult clients. The nurse should ask if the older adult client has been losing weight without trying to determine if the weight loss is unintentional. Asking if the older adult client has always been underweight does not address the potential for health care problems that may have caused the low BMI.
During an assessment the nurse notes that the gum tissue around an older adult client's teeth are red, swollen, and inflamed. Which will be the nurse's focus during client education? A. Swish with alcohol-based antiseptic mouthwash. B. Plan to obtain dentures. C. Brush with an electric toothbrush. D. Floss in areas that are not inflamed.
C. Brush with an electric toothbrush, Explanation: Gingivitis is an inflammation of the gums surrounding the teeth. Using an electric toothbrush will improve brushing technique and lessen the plaque that causes gingivitis. The client should use natural mouthwash that does not include alcohol to prevent irritation. The client should floss daily in all areas of the mouth. Gingivitis can be reversed with proper oral care and tooth loss requiring dentures is not a definite outcome.
The nurse is assessing an older adult client's food journal after receiving education to help the client to gain weight. When reviewing the client's entries, what information demonstrates the client has implemented the teaching provided? (repeated 1x) A. Lunch and dinner noted. B. Breakfast, lunch and dinner noted. C. Five to six small meals per day noted. D. Breakfast, dinner and bedtime snack noted.
C. Five to six small meals per day noted. Explanation: An older adult who is experiencing weight loss should be instructed to eat five to six small meals a day, providing a regular caloric intake without getting overfull. Eating less meals, or meals that are too large may prevent eating on a regular basis that will promote weight gain.
An older adult client reports having a dry mouth after being diagnosed with thrush. Which recommendation will the nurse make to this client? A. Eat foods that increase salivation. B. Include salty foods in your meals. C. Rinse your mouth with warm saltwater. D. Drink decaffeinated coffee.
C. Rinse your mouth with warm saltwater. Explanation: Rinsing the mouth with warm saltwater will soothe the mouth and stimulate saliva production. Eating salty foods will make the mouth feel drier. Drinking coffee can lead to dehydration and a lack of moisture in the mouth. The action of eating certain foods does not increase salivation. It is the action of chewing or sucking on foods such as a popsicle that causes salivation to increase.
A nurse evaluates the plan of care for a client who experienced an ischemic stroke. Which assessment finding should signal the nurse to the possibility that the client has developed dysphagia? A. The client prefers to sit in a high Fowler position after eating. B. The client reports being excessively hungry. C. The client pockets food in the affected cheek during meals. D. The client drinks large amounts of water with meals.
C. The client pockets food in the affected cheek during meals. Explanation: Pocketed food suggests dysphagia. Sitting upright after meals prevents, rather than indicates, dysphagia and neither hunger nor high fluid intake is indicative of dysphagia.
An older adult client has a history of a deep vein thrombosis. The client should be taught to avoid excessive intake of which vitamin or nutrient? A. Calcium B. Vitamin D C. Vitamin K D. Potassium
C. Vitamin K Explanation: High doses of vitamin K can result in the formation of blood clots. Excess vitamin D can result in calcium deposits in the kidneys and arteries. Calcium in excess can lead to kidney stones. Excess potassium can lead to cardiac abnormalities.
An older adult client with controlled chronic illnesses has no interest in eating and is losing weight. What should the nurse assess first? (repeated 1x) A. dentition B. ability to swallow C. reason for no interest in eating D. finances
C. reason for no interest in eating Explanation: The initial step when managing anorexia is to identify the cause. Finances, dentition, and difficulty with the ability to swallow all may be reasons why the client is losing weight; however, there might be another reason why the client has lost interest in eating.
The nurse notes that an older adult client has difficulty swallowing a bolus of food when eating. Which suggestion will the nurse make to the health care provider based upon this observation? A. parenteral nutrition B. liquid diet C. nasogastric tube for enteral feedings D. referral to a speech-language pathologist
C. referral to a speech-language pathologist Explanation: For the client with a problem swallowing, a referral to a speech-language pathologist is essential to developing an effective plan of care. A liquid diet could lead to aspiration. Parenteral nutrition or a nasogastric tube for enteral feedings is an extreme intervention at this time.
A frail older adult client who has slowly been losing weight states, "I just feel so full so full, I cannot eat any more." Which initial recommendation will the nurse make? A. Make an appointment with your health care provider. B. Restrict fluids during meals. C. Increase exercise. D. Eat five small meals during the day.
D. Eat five small meals during the day. Explanation: Slight slowing of gastric emptying in older adults after ingestion of large meals leads to early sensations of fullness. The nurse will recommend the client eat 5 small meals throughout the day. Restriction of fluid or increase in exercise will not resolve this issue. Making an appointment with the health care provider is not an initial intervention the nurse would recommend the client use to improve the problem.
The nurse notes that an older adult client experiencing weight loss has several missing teeth and the remaining teeth have evidence of gum erosion. Which intervention will the nurse include in the plan of care? A. Weigh monthly. B. Limit sugars. C. Use lemon glycerin swabs for oral care. D. Order a soft diet.
D. Order a soft diet. Explanation: The nurse will order a soft diet so the client can eat nutritious food that is easily on the mouth. Oral care is important but lemon glycerin swabs may cause burning in the mouth. Limiting sugar is not a requirement but the client should eat nutritious meals, due to weight loss the client should be weighed at least weekly to determine progress to goals.
The nurse observes the unlicensed assistive personnel provide mouth care to an older client. For which observation should the nurse intervene? A. Diluted mouthwash with water before providing B. Applied a small amount of toothpaste onto a toothbrush C. Dampened the toothbrush with a small amount of water D. Swabbed the lower back molars with lemon-glycerin swabs
D. Swabbed the lower back molars with lemon-glycerin swabs Explanation: Lemon-glycerin swabs dry the oral mucosa and contribute to tooth enamel erosion. They should not be used. The use of a toothbrush is more effective in improving gingival tissues and removing soft debris from the teeth. Mouthwashes with high alcohol content can be too harsh for older mouths; diluting a commercial mouthwash with water (half and half) is recommended.
A nurse admits an older adult client to the hospital with a diagnosis of failure to thrive. Which laboratory data should the nurse expect? (repeated 1x) A. white blood cells 14,300 cells/μL (14.3 x 109/L) and potassium 3.2 mEq/L (3.2 mmol/L) B. platelets 124 x 103/μL (124 x 109/L) and prothrombin time (PT) 10.9 sec C. calcium 14.2 mg/dl (3.55 mmol/L) and magnesium 3.2 mg/dl (1.32 mmol/L) D. albumin 2.8 g/dl (28 g/L) and red blood cells 4.1 x 106/μL (4.1 x 1012/L)
D. albumin 2.8 g/dl (28 g/L) and red blood cells 4.1 x 106/μL (4.1 x 1012/L) Explanation: Anemia and low serum albumin levels are consistent with malnutrition. Elevated white blood cells, calcium, and magnesium and low platelets and prothrombin time are not characteristic of malnutrition.
The older adult client needs further teaching about quality of calorie intake when listing which frequently eaten foods? A. baked pork chops, salads, assorted fruits B. baked chicken, oatmeal, eggs C. fish or chicken, fruit smoothies, whole grain bread D. hamburger meat, green vegetables, whole grain crackers
D. hamburger meat, green vegetables, whole grain crackers Explanation: Limiting dietary fat intake to less than 30% of total calories consumed is a good practice for older adults. Hamburger meat can be high in fat. Lean meats such as chicken, pork, and fish are healthy, in addition to whole grains, fruits, vegetables, and low-fat dairy products.
An older adult client avoids eating pork rinds because they cause gastric distress. Which age-related change in digestion is this client experiencing? A. decrease in the size of the liver B. change in the size of the gallbladder C. decreased excretion of gastric acid D. pancreatic atrophy
D. pancreatic atrophy Explanation: Pancreatic atrophy reduces pancreatic secretions, which affects the digestion of fats and contributes to an intolerance for fatty foods. Decreased size of the liver does not affect fat metabolism. The gallbladder size does not change with aging. Gastric secretions increase with aging.
A health care provider has prescribed a calcium supplement for an older adult client. Which other important nutrients should the nurse teach the client to eat to promote calcium absorption? A. vitamin E and potassium B. potassium and vitamin K C. sodium and vitamin B12 D. vitamin D and magnesium
D. vitamin D and magnesium Explanation: The nurse should include in the teaching that a good intake of vitamin D and magnesium facilitates calcium absorption. Potassium and vitamin K, sodium and vitamin B12, and vitamin E and potassium are not included in the teaching because they do not have significant effects on the reabsorption of calcium.
An older adult client reports new-onset diarrhea. The client's vital signs are stable. Which action will the nurse implement? Review the client's medication list
Explanation: The nurse will review the client's medication list. A number of medications can cause diarrhea in the older adult client (e.g., cimetidine, laxatives, antibiotics, cardiovascular drugs, and cholinesterase inhibitors). Additionally, Clostridium difficile and its related diarrhea are related to antibiotic usage. Acute pancreatitis may result in abdominal pain, fever, bloating, and diarrhea. There are no indications of the additional symptoms in the scenario. Determining the last bowel movement assesses the frequency of the stools but does not help determine the underlying cause of the diarrhea. There is no indication in the scenario that suggests the nurse should review meal preparation techniques with the client. Improper meal preparation can increase risks for developing diarrhea secondary to infection. Serving undercooked eggs, for instance could result in diarrhea and fever, secondary to salmonella. The client is afebrile.
The nurse on the medical unit is assessing an 87-year-old male client, diagnosed with a stroke, who started coughing while being fed by an unlicensed assistive personnel. The nurse notes that the client has a hoarse voice and is still coughing. Crackles were auscultated in lungs bilaterally. Vital signs: temperature, 98.2°F (36.8°C); heart rate, 76 beats/min; respiratory rate, 26 breaths/min; blood pressure, 124/62 mm Hg. Skin warm and dry, with poor turgor. The client is alert, and able to state name, place, and season, although their speech is garbled. The client is at highest risk for aspiration pneumonia as evidenced by coughing and respiratory rate.
Explanation: This client has difficulty swallowing (dysphagia) following a stroke, placing the client at risk for aspiration pneumonia. The client with difficulty swallowing may inhale food, fluids, and oral secretions into the lungs, increasing the risk for aspiration pneumonia. Coughing while eating is a sign of dysphagia that can lead to aspiration pneumonia. The client has an elevated respiratory rate of 26 breaths/min, which can be a sign of aspiration pneumonia. The normal respiratory rate for an older adult client ranges from 16 to 24 breaths/min. Following a stroke, the client may have dysphasia and difficulty expressing or understanding language due to a brain impairment, but it is not as high a priority as the risk for aspirating food or fluid into the lungs that may result in pneumonia. Malnutrition is a potential risk in the client with difficulty swallowing, but it is not an immediate risk and can be addressed after the risk for aspiration is treated. The client's blood pressure of 124/62 mm Hg is within normal range and does not support a risk for aspiration for pneumonia. Skin that is warm and dry is a normal finding and is not associated with aspiration pneumonia. The client's body temperature is within normal range; however, the thermoregulatory response to infection in the older adult client may be blunted. Poor skin turgor is associated with dehydration, not aspiration pneumonia.
The nurse is caring for a client 1 month after a cerebrovascular accident. Which assessment will the nurse perform first? Gag reflex
Explanation: A weak gag reflex increases the client's risk for aspiration. Therefore, the nurse will include the gag reflex when assessing the client. Appetite, weight, and bowel sounds, while important, are not an immediate priority when caring for a client 30 days after a cerebrovascular accident.
The nurse is teaching a class to older adults about oral health practices. What health promotion activity should the nurse recommend? Visit a dentist every six months to detect oral diseases
Explanation: For older adults, visiting a dentist every six months to detect oral diseases is necessary due to the risk for oral disease in this population. Less frequent visits are acceptable for those using a full set of dentures. Dental care should be proactive, not only on the basis of pain. Clients older than 80 years of age do not normally need to see a dentist every three months.
An older adult client has just completed eating breakfast. What action will the nurse take before beginning morning hygiene care? Offer the bed pan
Explanation: It is useful for an older adult client to attempt a bowel movement following breakfast, because the morning activity and ingestion of food and fluid following a period of rest stimulates peristalsis. Assisting the client with dressing occurs after morning hygiene care. There is no reason to assist the client to sit in a chair at this time. Ambulation can occur later if appropriate for the client's health status.
A nurse teaches an older adult about nutrition. Which statement shows the nurse that the older adult requires further teaching? "My over-the-counter beta-carotene pill is appropriate for long-term use."
Explanation: Long-term beta-carotene use can cause vitamin E deficiency. Paralytic ileus can occur with anticholinergic medication. Nutritional supplements and herbal preparations can affect nutrients. Alcohol interferes with the absorption of B-complex vitamins and vitamin C.
The nurse suspects that an older adult client is having problems with eating. What assessment finding may cause the nurse to make this clinical determination? dentures in a glass of water in the bathroom
Explanation: Not wearing the dentures could indicate that they are ill-fitting or uncomfortable. Conducting mouth care, seeing a dentist regularly, and having the dentures fitted and adjusted would not indicate a problem with the dentures.
A 78-year-old client reports heartburn on a regular basis after eating. Which topic will the nurse include in the teaching plan? Eat smaller meals.
Explanation: Regular heartburn can be a sign of gastrointestinal reflux. The nurse will refer the client to the health care provider. In the meanwhile, the nurse will recommend the client eat small meals that are easier to digest and require less stomach acid. Including milk or wine with meals or laying down may exacerbate the symptoms.
An older adult client is embarrassed because of increased flatulence. What will the nurse recommend to this client? Sit upright after meals
Explanation: Sitting upright after meals is helpful in allowing flatulence, or gas, to rise to the fundus of the stomach and be expelled. Consuming meals faster may increase flatulence as more air is typically swallowed when eating faster. The increased swallowed air becomes flatulence. Warm tea has no therapeutic effect on the development of flatus. Flatus is not caused by drinking fluids with meals.
A client's family brings an older adult family member to the emergency department, stating, "My parent is not eating well." The nurse should assess for which sign of malnutrition? Serum albumin level 2.7 g/dl (27g/L)
Explanation: Some of the clinical signs of malnutrition include: weight 10% below or 20% above the ideal range; serum albumin level lower than 3.5 g/dL (35 g/L); hemoglobin level below 12 g/dL (120 g/L); hematocrit value below 35% (0.35).
An older adult client does not like to drink water and drinks only a few cups of tea each day. What should the nurse suggest the client ingest to increase this client's intake of fluids? Soup
Explanation: Soup can help increase the daily fluid intake in an older adult client. Ice is frozen water; however, it would take a considerable amount of ice to have an appreciable effect on fluid intake. Celery and cucumbers have a high water content; however, a considerable amount of these vegetables would have to be eaten to have an appreciable effect on fluid intake.
The nurse in the primary care clinic is taking a history from an 82-year-old female client being seen for an annual physical. The client lives at home and is alert and oriented to time, place, and person. The client reports that they do not exercise and eat mostly processed foods with few fruits and vegetables. The client also reports limiting fluid intake so they do not need to go to the bathroom frequently. Vital signs: temperature, 98.2°F (36.8°C); heart rate, 72 beats/min; respiratory rate, 16 breaths/min; blood pressure, 138/74 mm Hg. Client has hypertension treated with hydrochlorothiazide and osteoarthritis treated with ibuprofen. The nurse assess that the client is at risk for cholelithiasis due to blood pressure and heart rate.
Explanation: This client is at risk for constipation due to a low-fiber diet and reduced fluid intake. This client's sedentary lifestyle also increases the risk for constipation. This client consumes a diet low in fiber. The client consumes processed foods, which are low in fiber, and has a low intake of fruits and vegetables that are high in fiber. Without fiber to increase the bulk of stool and soften it, the client is at risk for constipation. Adequate fluid intake is necessary to keep water from being drawn from the stool, keeping the stool soft. Because this client reports a reduced fluid intake, the client is at risk for hard stools and constipation. Fecal incontinence in older adult clients typically results from fecal impaction (the inability to voluntarily control the passage of stool) in those who are institutionalized or physically or cognitively impaired. This client lives at home and is oriented to time, place, and person. Cholelithiasis (gallstones in the gallbladder) are caused by bile containing too much cholesterol or bilirubin, or not enough bile salts. Eating processed foods and a lack of fruits and vegetables does not contribute to gallstones. Hypertension and a high-sodium diet from processed foods do not increase the risk of constipation. The client's heart rate and use of ibuprofen do not contribute to constipation.
The nurse is caring for a client who is diagnosed with xerostomia related to age-related decline in saliva production. Which intervention will the nurse implement for this client? (repeated 1x) A. Drink carbonated beverages. B. Sip cold water throughout the day. C. Avoid fluids at mealtime. D. Suck on hard candy during the day.
Suck on hard candy during the day. Explanation: The nurse should recommend the client chew sugarless gum or suck on sugarless candy because these actions can stimulate salivary flow. The nurse should recommend the client sip room-temperature water throughout the day and night and avoid drinking water at an extreme water temperature (very hot or very cold) which can inhibit salivary flow. The client should avoid carbonated beverages, because they often contain sodium that can cause dryness of the mouth. Drinking at mealtime helps to moisten food to ease consumption.
The nurse in the primary care clinic is taking a history from an 82-year-old female client being seen for an annual physical. The client lives at home and is alert and oriented to time, place, and person. The client reports that they do not exercise and eat mostly processed foods with few fruits and vegetables. The client also reports limiting fluid intake so they do not need to go to the bathroom frequently. Vital signs: temperature, 98.2°F (36.8°C); heart rate, 72 beats/min; respiratory rate, 16 breaths/min; blood pressure, 138/74 mm Hg. Client has hypertension treated with hydrochlorothiazide and osteoarthritis treated with ibuprofen. The nurse assesses that the client is at risk for constipation due to low-fiber diet and fluid volume deficit.
This client is at risk for constipation due to a low-fiber diet and reduced fluid intake. This client's sedentary lifestyle also increases the risk for constipation. This client consumes a diet low in fiber. The client consumes processed foods, which are low in fiber, and has a low intake of fruits and vegetables that are high in fiber. Without fiber to increase the bulk of stool and soften it, the client is at risk for constipation. Adequate fluid intake is necessary to keep water from being drawn from the stool, keeping the stool soft. Because this client reports a reduced fluid intake, the client is at risk for hard stools and constipation. Fecal incontinence in older adult clients typically results from fecal impaction (the inability to voluntarily control the passage of stool) in those who are institutionalized or physically or cognitively impaired. This client lives at home and is oriented to time, place, and person. Cholelithiasis (gallstones in the gallbladder) are caused by bile containing too much cholesterol or bilirubin, or not enough bile salts. Eating processed foods and a lack of fruits and vegetables does not contribute to gallstones. Hypertension and a high-sodium diet from processed foods do not increase the risk of constipation. The client's heart rate and use of ibuprofen do not contribute to constipation.
