A nurse in a long-term care facility is implementing a nutrition plan for a client who is at risk for malnutrition. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Remove the bedpan from the client's sight.

Provide mouth care before feeding.

Assess for pain prior to mealtime.

Administer antiemetics following the meal.

Answer and Explanation

Correct Answer : B,C

A) Remove the bedpan from the client's sight: This action is not directly related to addressing malnutrition. While it may improve the client's comfort and environment, it does not contribute directly to addressing nutritional needs.

B) Provide mouth care before feeding: This action is appropriate. Ensuring good oral hygiene, including mouth care before meals, can stimulate the appetite and enhance the client's ability to taste and enjoy food. It also helps prevent infections and discomfort associated with poor oral hygiene.

C) Assess for pain prior to mealtime: This action is essential. Pain can significantly affect a client's appetite and ability to eat. By assessing for pain before mealtime, the nurse can identify any discomfort that might interfere with the client's ability to consume food and address it promptly.

D) Administer antiemetics following the meal: While antiemetics may be necessary for some clients who experience nausea or vomiting during or after meals, their administration should be based on individual assessment and prescription by a healthcare provider. Routine administration of antiemetics following meals is not standard practice and may not be appropriate for all clients.

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Correct Answer is C

Explanation

Gastroesophageal reflux (GER) is a common condition in infants where the contents of the stomach flow back into the esophagus. It often resolves on its own as the infant grows, but management strategies can help alleviate symptoms. Positioning the newborn upright or at a slight angle after feeding is a key recommendation to reduce reflux episodes.

Now, let's review the rationales for each option:

A) "Provide a small feeding just before bedtime." - Feeding a newborn just before bedtime can exacerbate reflux symptoms as lying down can increase the likelihood of stomach contents refluxing into the esophagus. Therefore, this instruction is not recommended as it may worsen GER symptoms.

B) "Dilute formula with 1 tablespoon of water." - Diluting formula with water can disrupt the balance of nutrients and calories in the formula, potentially affecting the infant's growth and nutritional status. Additionally, diluting formula does not address the underlying cause of GER and is not a recommended practice.

C) "Position the newborn at a 20-degree angle after feeding." - This instruction is correct. Placing the newborn at a 20-degree angle or slightly upright after feeding can help reduce the occurrence of reflux episodes by allowing gravity to assist in keeping stomach contents down. This position helps prevent the backflow of gastric contents into the esophagus and reduces discomfort for the infant.

D) "Place the newborn in a side-lying position if vomiting." - Placing the newborn in a side-lying position after vomiting may increase the risk of aspiration, especially in young infants. It is safer to position the infant upright or at a slight angle to minimize reflux and reduce the risk of aspiration.

A. "Consume foods that are high in calcium." B. "Increase intake of refined carbohydrates." C. "Consume ten percent of total calories from saturated fat." D. "Limit sodium intake to 3,200 milligrams per day."

Correct Answer is A

Explanation

Answer: A

Rationale:

A. Consume foods that are high in calcium: The DASH diet emphasizes the consumption of foods rich in calcium, as well as potassium and magnesium. Adequate calcium intake is important for managing hypertension, making this a key component of the diet.

B. Increase intake of refined carbohydrates: The DASH diet recommends reducing refined carbohydrates and focusing on whole grains. Refined carbohydrates can contribute to weight gain and adversely affect blood pressure, so increasing their intake is not advised.

C. Consume ten percent of total calories from saturated fat: The DASH diet suggests limiting saturated fat to less than 6-7% of total daily calories. Consuming ten percent of total calories from saturated fat exceeds the recommended amount and is not consistent with DASH guidelines.

D. Limit sodium intake to 3,200 milligrams per day: The DASH diet recommends limiting sodium intake to 1,500 milligrams per day, not 3,200 milligrams. Reducing sodium intake is crucial for controlling blood pressure and aligning with DASH diet principles.

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A nurse in a long-term care facility is implementing a nutrition plan for a client who is at risk for malnutrition. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Nursing Test Bank

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