A client who has been breastfeeding an infant for 6 months reports having a dry mouth and skin. Which recommendation(s) should the nurse provide to the client? Select all that apply.

Drink an additional liter of water each day.

Restrict cola drinks to three a day.

Limit coffee to one serving a day.

Sip on unsweetened fruit juices during the day.

Replace one meal a day with a liquid supplement.

Answer and Explanation

Correct Answer : A,C,D

A. This is a primary recommendation. Breastfeeding increases fluid requirements, and symptoms of dry mouth and skin indicate mild dehydration. Adequate hydration supports milk production and overall maternal health. Encouraging water intake is the safest and most effective intervention.

B. Limiting sugary or caffeinated beverages is generally beneficial, but suggesting a specific number of colas is less relevant than addressing hydration with healthy fluids. Cola also contributes little to hydration and contains caffeine, which can have a mild diuretic effect.

C. Reducing caffeine intake helps prevent dehydration. While moderate caffeine is generally safe for breastfeeding, excessive intake can contribute to dry mouth, fluid loss, and possible irritability in the infant.

D. Unsweetened fruit juices contribute to fluid intake and provide some vitamins without excessive sugar, making them an appropriate way to maintain hydration.

E. This is not necessary solely for hydration. Meal replacement shakes may provide calories but do not directly address dry mouth or fluid balance. Regular balanced meals are preferable unless dietary intake is inadequate.

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Correct Answer is D

Explanation

A. Liver function tests, including AST, ALT, and ALP, are used to assess hepatic injury or disease. While important in certain contexts, liver enzymes are not directly affected by diverticulitis. Monitoring these values would only be necessary if the client had pre-existing liver disease, was taking hepatotoxic medications, or had symptoms suggestive of liver dysfunction. In the acute management of diverticulitis, liver enzymes do not provide timely information about the infection or inflammation severity.

B. Platelet counts are monitored to evaluate clotting function or risk of bleeding. Acute diverticulitis is not typically associated with thrombocytopenia or bleeding unless there is an unusual complication. Therefore, platelet count is not the priority lab value in assessing the client’s response to diverticulitis treatment.

C. Serum albumin reflects nutritional status and chronic protein stores, and hypoalbuminemia can indicate malnutrition or chronic illness. While the client’s nausea and vomiting may eventually affect nutrition, changes in albumin occur gradually over days to weeks. It does not provide immediate information about the acute infection or inflammatory response, so it is not the most important lab to monitor in the acute phase.

D. WBC is the most critical laboratory value to monitor in acute diverticulitis. Diverticulitis involves inflammation and often infection of diverticula in the colon, which triggers an immune response. A high WBC count (leukocytosis) indicates active infection or inflammation, while trends in WBC levels help the healthcare team determine whether antibiotic therapy is effective or if complications, such as abscess formation, perforation, or sepsis, are developing. Monitoring WBC is crucial to early detection of worsening illness and timely interventions.

A. At-risk clients received an increased number of routine health screenings. B. More than 60% of clients taking rifampin completed the course of therapy. C. Overcrowding in prisons was addressed at a local town hall meeting. D. Clients report having new confidence in avoiding people who are coughing.

Correct Answer is B

Explanation

A. Increasing routine health screenings represents primary prevention strategies, which aim to identify health risks before disease occurs, not interventions targeted at clients already at risk or exposed to tuberculosis.

B. This is the correct choice because secondary prevention focuses on early detection and treatment of disease to prevent progression and complications. Tuberculosis therapy adherence, such as completing a rifampin course, directly reflects effective secondary prevention by treating latent or active infection and preventing further spread.

C. Addressing overcrowding in prisons is a community-level primary prevention effort aimed at reducing TB transmission risk, but it does not reflect the effectiveness of a secondary prevention program directed at already at-risk or infected individuals.

D. Clients reporting confidence in avoiding sick people reflects health education and behavioral change, which is more aligned with primary prevention and health promotion, rather than measurable outcomes of secondary prevention like disease detection or treatment completion.

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A client who has been breastfeeding an infant for 6 months reports having a dry mouth and skin. Which recommendation(s) should the nurse provide to the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted for treatment of acute diverticulitis with associated nausea and vomiting. Which serum laboratory value is most important for the nurse to monitor during the client's treatment?

Correct Answer is D

Explanation

The nurse implements a secondary prevention program for tuberculosis in a rural health clinic. Which outcome indicates that the program was effective?

Correct Answer is B

Explanation

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