A client with severe malnutrition is admitted to the hospital.
Which intervention should the nurse implement first?

Insert nasogastric tube and begin enteral feeding.

Teach the patient to increase protein intake and to eat five to seven times a day.

Implement strict NPO status and initiate total parenteral nutrition (TPN).

Teach the patient to rinse their mouth with alcohol-based mouthwash prior to meals.

Answer and Explanation

The Correct Answer is A

Choice A rationale

For a client with severe malnutrition, immediate intervention is necessary to address nutritional deficiencies. Inserting a nasogastric tube and beginning enteral feeding is the first step to provide essential nutrients, stabilize the patient's condition, and prevent further complications from malnutrition.

Choice B rationale

Teaching the patient to increase protein intake and to eat more frequently is important but not the immediate priority in a case of severe malnutrition. This can be addressed after initial stabilization and nutritional support.

Choice C rationale

Total parenteral nutrition (TPN) is an option for patients who cannot tolerate enteral feeding, but initiating strict NPO status without first attempting enteral feeding is not the best initial approach. Enteral feeding is generally preferred if the gastrointestinal tract is functional.

Choice D rationale

Rinsing the mouth with alcohol-based mouthwash before meals is not a priority in managing severe malnutrition. It does not address the immediate need for nutritional support and could be harmful if ingested.

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Correct Answer is A

Explanation

Choice A rationale

Hypercalcemia is common in patients with bone metastasis. Symptoms include weakness, fatigue, confusion, and excessive thirst. The nurse should notify the provider and draw blood to obtain the ionized calcium level for proper diagnosis and treatment.

Choice B rationale

Tumor lysis syndrome typically occurs in patients with rapidly proliferating tumors undergoing treatment, leading to the release of intracellular contents. Symptoms include hyperuricemia, not excessive thirst. This choice does not match the patient's presentation.

Choice C rationale

While infection can cause weakness and confusion, it does not typically cause extreme thirst. The patient's symptoms are more indicative of hypercalcemia, making this choice less relevant.

Choice D rationale

Bleeding can cause weakness and confusion due to anemia, but it does not cause extreme thirst. The symptoms of the patient are more aligned with hypercalcemia than bleeding.

A. Administer isotonic intravenous fluid bolus and loop diuretic. B. Administer STAT anticoagulants and supplemental oxygen via nasal cannula. C. Perform frequent neurologic assessments and administer intravenous corticosteroids. D. Administer interferon beta-1a injections and assist the patient with stretching.

Correct Answer is C

Explanation

Choice A rationale

Administering isotonic intravenous fluids and a loop diuretic is a treatment for conditions like hypercalcemia or fluid overload but is not appropriate for a patient with metastatic prostate cancer presenting with neurologic symptoms.

Choice B rationale

Administering anticoagulants and supplemental oxygen is a treatment for pulmonary embolism but does not address the neurologic symptoms and back pain related to metastatic prostate cancer.

Choice C rationale

Frequent neurologic assessments and administering intravenous corticosteroids are essential for managing spinal cord compression, a common complication in metastatic prostate cancer that can cause back pain, weakness, and paresthesia.

Choice D rationale

Interferon beta-1a is used in multiple sclerosis to reduce inflammation and immune response. Stretching exercises may help but are not the primary intervention for acute neurologic symptoms in metastatic prostate cancer. .

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A client with severe malnutrition is admitted to the hospital.Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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A client with severe malnutrition is admitted to the hospital.
Which intervention should the nurse implement first?