A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
Encourage mouth care before and after meals.
Monitor the client for changes in mental status.
Assess the client's laboratory work for increased calcium levels.
Advise the client to keep a food diary.
Instruct the client to drink extra fluids between meals.
Correct Answer : A,B,D,E
A. Encouraging mouth care before and after meals helps maintain oral hygiene, which is essential for appetite stimulation and preventing oral infections.
B. Monitoring the client for changes in mental status is important as malnutrition can lead to cognitive impairment and changes in mental status.
C. Assessing the client's laboratory work for increased calcium levels may not be directly related to malnutrition due to cancer. Elevated calcium levels are more commonly associated with conditions like hyperparathyroidism or certain cancers, but it's not typically a direct consequence of malnutrition.
D. Advising the client to keep a food diary helps track food intake, identify any patterns related to malnutrition, and guide dietary interventions.
E. Instructing the client to drink extra fluids between meals helps prevent dehydration, especially if the client's intake is compromised due to malnutrition or cancer-related treatments.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Check an apical pulse: Digoxin is known to cause toxicity, which can manifest as nausea, weakness, and anorexia. Bradycardia is a common sign of digoxin toxicity. Therefore, the nurse's first action should be to assess the client's apical pulse rate to determine if there are any signs of bradycardia, which could indicate digoxin toxicity.
B. Request a dietitian consult: While nutrition is important, the client's symptoms of nausea and weakness need immediate attention to rule out digoxin toxicity before considering dietary interventions.
C. Request an order for an antiemetic: Administering an antiemetic may be indicated if the client is experiencing nausea, but it's crucial to assess for digoxin toxicity first, as antiemetics may mask symptoms of toxicity.
D. Suggest that the client rests before eating the meal: Rest may be beneficial for the client, but addressing the potential cause of the symptoms, such as digoxin toxicity, takes priority
Correct Answer is B
Explanation
A. Hamburger on a bun, banana: This choice is high in protein and potassium, which may not be suitable for someone with chronic renal disease, as excessive potassium intake can be harmful to individuals with impaired kidney function.
B. Carrots, green leafy vegetables, a pear: This choice is low in potassium and phosphorus, making it suitable for someone with chronic renal disease. Carrots and green leafy vegetables are generally lower in potassium, and a pear is a low-potassium fruit option.
C. Spaghetti with meat sauce, breadstick: This choice may be high in protein and sodium, depending on the sauce and breadstick ingredients, which may not be ideal for someone with chronic renal disease.
D. Cold cuts with bun, blueberries: Cold cuts can be high in sodium, and blueberries are moderately high in potassium, so this choice may not be appropriate for someone with chronic renal disease.
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