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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Bruising: Bruising is more commonly associated with platelet disorders or clotting deficiencies rather than low calcium levels. It does not directly relate to the neuromuscular symptoms caused by hypocalcemia.
B. Pallor: Pallor is often a sign of anemia or poor perfusion, not a specific indicator of low serum calcium levels. While important to observe, it is not the most relevant concern in hypocalcemia.
C. Tetany: Tetany, characterized by muscle cramps, spasms, and sometimes severe convulsions, is a classic symptom of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to these involuntary muscle contractions, which require immediate monitoring and intervention.
D. Jaundice: Jaundice reflects elevated bilirubin levels, typically related to liver dysfunction, not calcium imbalance. It would not be expected in a client primarily experiencing malabsorption-induced hypocalcemia.

A. Alteration in comfort. B. Deficit in diversional activity. C. Elevated blood pressure. D. Change in blood glucose level.

Correct Answer is A

Explanation

A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a malabsorption syndrome has a low serum calcium level. The practical nurse should monitor the client for which problem?

Correct Answer is C

Explanation

The practical nurse (PN) is providing care for a client with a history of a stroke and who has aphasia. The client is exhibiting restlessness, shallow respirations and is clenching teeth. Which problem should the PN assess further?

Correct Answer is A

Explanation

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