nutrition NUR104
A nurse researching a diet for a client with diabetes includes foods that supply energy to the body. Which are classes of nutrients that supply this energy? Select all that apply.
Proteins Fats Carbohydrates Explanation: Of the six classes of nutrients, three supply energy (carbohydrates, proteins, lipids [fats]) and three are needed to regulate body processes (vitamins, minerals, water).
A client has a history of long-term alcohol abuse. Which of the following nutrients would need to be required in increased amounts?
Vitamin B Explanation: The use of alcohol depletes the production of B vitamins in the liver; thus, they would need to be replaced.
The nurse is teaching an older adult client about different types of proteins that can be eaten. Which food will the nurse identify that contain dietary protein? (Select all that apply.)
beans nuts poultry fish Explanation: Dietary proteins are obtained from animal and plant food sources, which include milk, meat, fish, poultry, eggs, soy, legumes (peas, beans, and peanuts), nuts, and components of grains. Butter is a fat and not a source of protein.
A nurse is assessing a postmenopausal client with osteoporosis. Which factors contribute to the development of osteoporosis in postmenopausal women and in older adult men? Select all that apply.
decreased physical activity smoking heredity factors and race Explanation: Factors contributing to the development of osteoporosis may include decreased physical activity, smoking, heredity factors, and race. Other factors include a chronically insufficient calcium intake and decreased estrogen level. Malabsorption syndromes can lead to problems in calcium absorption, causing osteoporosis.
The nurse is teaching the caregiver of a toddler about the importance of calcium to help a child's teeth and bones develop properly. Which client statement reflects that nursing teaching has been effective?
"I will be sure to provide milk at meals." Explanation: Milk and milk products contain calcium. Orange juice contains vitamin C. Meats contain protein. Plants contain multiple vitamins and minerals, yet may not meet the growing child's need for calcium when consumed alone.
The nurse is providing discharge teaching for a client who will continue to administer tube feedings at home. The client states, "I don't think I can do this." What is the appropriate nursing response?
"Perhaps we can contact a home health nurse to assist." Explanation: A home health nurse can be of assistance if a client is afraid or unable to self-administer tube feedings. Reassuring the client, inquiring who will feed the client, and why the client is afraid do not effectively address the client's need.
A nurse is establishing an ideal body weight for a 5'9" (175 cm) healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?
145 lb/ 65.7 kg Explanation: A general guideline, often called the rule-of-thumb method, determines ideal weight based on height. This formula is as follows: For adult females: 100 lb/45.3 kg (for height of 5 feet or 152 cm) + 5 lb / 2.2 kg for each additional inch (2.5 cm) over 5 feet. For adult males: 106 lb / 48 kg (for height of 5 feet) + 6 lb / 2.7 kg for each additional inch over 5 feet.
A client is receiving a continuous tube feeding using a commercially prepared formula at home. The nurse would instruct the client's caregiver to use the formula within which time frame once the container is opened?
24 hours Explanation: After opening a commercially prepared formula, the container should be sealed and stored in the refrigerator and used within 24 hours. Clients receiving continuous tube feedings should have gastric residuals checked every 4 to 6 hours.
What is the body mass index (BMI) of a client who is 1.68 meters tall and weighs 70 kg?
24.8 Explanation: A BMI of 24.8 is correct. The BMI is the ratio of height to weight that more accurately reflects total body fat stores in the general population. It is equal to: weight in kg/height in m2.
A nurse is discussing vitamin supplementation. Which groups are more prone to mild vitamin deficiencies? Select all that apply.
Adolescents Pregnant or lactating women Strict vegetarians Explanation: Adolescents often eat fast food or skip breakfast. Pregnant or lactating women have higher nutritional demands. Strict vegetarians are also prone to vitamin deficiencies. Middle aged adults and non-smokers are not at risk.
A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition?
Anorexia Explanation: The nurse should document the loss of appetite following prolonged illness as anorexia. Emaciation is excessive leanness. Cachexia is the general wasting away of body tissue. Nausea usually precedes vomiting and is associated with gastrointestinal sensations.
The nurse is attempting to insert an NG tube and, as the tube is passing through the pharynx, the client begins to retch and gag. What nursing interventions are appropriate in this situation? Select all that apply.
Ask the client if he needs to pause before continuing insertion. Continue to advance tube when the client relates that he is ready. Have the emesis basin nearby in case client begins to vomit. Explanation: The nurse would ask the client if she should pause before continuing insertion of the NG tube. The client retching and gagging is often part of the normal process of placing an NG tube. The nurse would continue to advance the tube when the client states he is ready. The emesis basin should be nearby in case the client begins to vomit. The nurse would not inspect the other nostril; if the client is retching and gagging, the issue is not the nostril. The nurse would not give small air boluses or insert a nasointestinal tube.
A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first?
Elevate the head of the bed. Explanation: The head of the bed should be elevated before giving medications or performing a tube feeding. Following this, the placement of the tube should be checked, aspirate the gastric contents with a syringe, and then flush the tube with the ordered amount of water.
A nurse is caring for a client with a gastrostomy tube in place. What is an accurate guideline for care of the insertion site?
If the gastric tube insertion site has healed and the sutures are removed, use soap and water to clean the site. Explanation: If the gastrostomy tube is new and still has sutures holding it in place, dip a cotton-tipped applicator into sterile saline solution and gently clean around the insertion site, removing any crust or drainage. Avoid adjusting or lifting the external disk for the first few days after placement except to clean the area. If the gastric tube insertion site has healed and the sutures are removed, wet a washcloth and apply a small amount of soap onto it. Gently cleanse around the insertion site, removing any crust or drainage.
Which statement accurately describes a step in the administration of a tube feeding?
Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time. Explanation: Intermittent feedings are delivered at regular intervals, using gravity for instillation or a feeding pump to administer the formula over a set period of time. The steps for administering feedings are similar regardless of the tube used. Intermittent feedings are the preferred method of introducing the formula over a set period of time via gravity or pump. Feeding intolerance is less likely to occur with smaller volumes.
The nurse is teaching a new mother who is not breast-feeding her infant. What nutrient must be supplemented by the mother?
Iron Explanation: Breast-fed infants receive all the nutrients from their mother; those who are bottle fed need iron supplements in the form of formula or cereal. Vitamin C, calcium and protein do not need to be supplemented.
What consideration based on gender would a nurse make when planning a menu for a male client with well-defined muscle mass?
Men have a higher need for proteins. Explanation: Due to the higher percentage in muscle mass in men, they have a higher need for proteins in their diet. Men do not have a lower need for carbohydrates, minerals, or vitamins.
The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate?
Speak to the client but limit the need for the client to respond verbally while chewing and swallowing. Explanation: Clients who have dysphagia need to eat slowly and be continually observed for signs of aspiration.
A female client tells the nurse, "I try to consume 2000 calories daily by eating a variety of proteins, carbohydrates, and fats." What is the appropriate nursing response?
That is a healthy amount of daily caloric intake." Explanation: Healthy adult women on average require 1800 to 2400 cal/day, with a mix of proteins, carbohydrates, and fats. The nurse should affirm the client's dietary choices. Other answers are incorrect and do not counsel the client appropriately. Reference:
A client with continuous vomiting requires gastrointestinal intubation. Which tube does the nurse anticipate inserting for gastric decompression?
nasogastric sump tube Explanation: Gastric sump tubes (double-lumen tubes) are used almost exclusively to remove fluid and gas from the stomach. Other options are incorrect.