A client on a prescribed full liquid diet has a nursing problem of, "Risk for impaired skin integrity related to reduced oral intake." Which snack would be best to provide this client?
A liquid nutritional supplement that contains protein.
Beef broth, or chicken broth.
Fortified lowfat milk.
Apple or grapefruit juice.
The Correct Answer is A
A. A liquid nutritional supplement that contains protein: A full liquid nutritional supplement with added protein is best because protein is critical for skin integrity and tissue repair. Supplements also provide balanced calories, vitamins, and minerals necessary to support overall skin health and prevent breakdown.
B. Beef broth, or chicken broth: While broth provides fluids and some electrolytes, it is very low in calories and protein, making it insufficient alone for preventing impaired skin integrity in a client with reduced oral intake.
C. Fortified lowfat milk: Milk offers some protein and nutrients, but a specialized nutritional supplement is more calorie-dense and protein-rich, providing a more comprehensive solution for a client at risk for skin breakdown.
D. Apple or grapefruit juice: Fruit juices offer hydration and some vitamins but lack significant protein and calories. They are inadequate for maintaining skin integrity, especially when protein intake is a primary concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Visitors should only wash hands with soap and water: Handwashing with soap and water is essential because alcohol-based sanitizers are ineffective against Clostridium difficile spores. Physical friction from washing removes spores and significantly reduces the risk of transmission.
B. Standard precautions apply to clients with active diarrhea: Clients with C. difficile require contact precautions, not just standard precautions, due to the high risk of environmental contamination and spore transmission through direct and indirect contact.
C. Clostridium difficile spores do not live long on surfaces outside of the host: C. difficile spores are very hardy and can survive on surfaces for long periods, sometimes weeks or months, making environmental cleaning and personal hygiene critical.
D. Only immunosuppressed family members should take precautions: All visitors and healthcare workers must use precautions, not just immunosuppressed individuals, because C. difficile is highly contagious and can infect healthy individuals through spore ingestion.
Correct Answer is D
Explanation
A. An older adult with a blood pressure of 140/88 mm Hg: This blood pressure is slightly elevated but is common in older adults. It does not require immediate intervention unless accompanied by other concerning symptoms like chest pain or altered mental status.
B. An adult who has a respiratory rate of 18 breaths/minute: A respiratory rate of 18 is within the normal adult range (12–20 breaths/minute) and does not suggest respiratory distress or require urgent intervention.
C. A preschooler with an oral temperature of 98.2° F (36.7° C): This temperature is normal for a preschooler, and no immediate action is needed as it falls well within the expected range for healthy children.
D. A one-month-old infant with a heart rate of 80 beats/minute: A normal heart rate for a one-month-old infant ranges from about 100–160 beats per minute. A heart rate of 80 is dangerously low (bradycardia) for an infant and warrants immediate intervention to assess for respiratory or cardiac compromise.
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