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.)
Assess for pain prior to mealtime.
Discourage snacks between meals.
Provide mouth care before feeding.
Remove the bedpan from the client's sight.
Administer antiemetics following the meal.
Correct Answer : A,C,D
In a nutrition plan for a client at risk for malnutrition, the nurse should include the following actions:
Assess for pain prior to mealtime: Pain can significantly impact a person's appetite and ability to eat. Assessing for pain before mealtime can help identify any discomfort that may hinder the client's ability to eat.
Provide mouth care before feeding: Proper oral hygiene is essential for maintaining a healthy appetite and preventing oral health issues that can affect eating. Providing mouth care before feeding helps ensure a clean and comfortable oral environment.
Remove the bedpan from the client's sight: Sight and smell can have a significant impact on a person's appetite. Removing the bedpan from the client's sight can help create a more pleasant dining environment and promote a better appetite.
However, the following actions should not be included in the plan:
Discourage snacks between meals: For clients at risk for malnutrition, it may be necessary to encourage nutrient-dense snacks between meals to increase caloric intake. Discouraging snacks may further contribute to malnutrition.
Administer antiemetics following the meal: Administering antiemetics following a meal is not a routine action in a nutrition plan. Antiemetics are typically used to treat nausea and vomiting, which may interfere with a person's ability to eat, but their administration should be based on specific symptoms and prescribed by a healthcare provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When a client is newly prescribed atorvastatin for dyslipidemia, it is important to assess their alcohol consumption. Atorvastatin is metabolized by the liver, and excessive alcohol consumption can interfere with the liver's ability to process medications properly. Alcohol use can also have adverse effects on lipid profiles and contribute to liver disease. Therefore, determining the client's alcohol consumption is crucial in assessing the appropriateness of atorvastatin therapy and potential risks.
"Do you exercise regularly?": While exercise is an important aspect of cardiovascular health and can contribute to the management of dyslipidemia, it is not the first question to ask in this specific situation. Assessing alcohol consumption is more critical as it directly affects the metabolism and potential interactions with atorvastatin.
"Do you regularly have your eyes examined?": Regular eye examinations are important for individuals with certain health conditions, such as diabetes, to monitor for complications like diabetic retinopathy. However, for a client who is newly prescribed atorvastatin for dyslipidemia, assessing alcohol consumption takes priority as it has a direct impact on the medication's effectiveness and potential side effects.
"Do you check your blood pressure daily?": Monitoring blood pressure is essential for individuals with hypertension or cardiovascular disease. However, in this case, the priority is assessing alcohol consumption due to its potential interactions with atorvastatin.
Correct Answer is C
Explanation
Muscle weakness is a finding that indicates the client is experiencing water intoxication. Muscle weakness is a symptom of water intoxication because the excessive intake of water dilutes the sodium levels in the blood, causing hyponatremia. Sodium is an electrolyte that helps maintain the balance of fluids in and around cells and also regulates muscle contraction. When sodium levels are too low, the cells swell and the muscles lose their ability to function properly.
Weak pulses are not a specific finding for water intoxication, as they can be caused by other factors such as decreased blood volume or inadequate cardiac output.
Hypernatremia is the opposite of hyponatremia, meaning high sodium levels in the blood. This can occur due to dehydration, excessive salt intake, or certain medical conditions, but not water intoxication.
Exaggerated reflexes are not typically associated with water intoxication. They may be seen in conditions such as hyperreflexia or certain neurological disorders.
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