During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

Medications need to be documented in the record for the physician's review.

The nurse needs to assess the patient for allergic reactions.

Certain drugs can affect the metabolism of nutrients.

Medications can affect one's memory and ability to identify food eaten in the last 24 hours.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While documenting medications is important for the physician's review, this is not the primary nutritional assessment reason for asking about medications. The focus here is on how medications interact with nutritional status.

Choice B rationale

Assessing for allergic reactions to medications is crucial for patient safety, but it is a separate aspect of medication history and not directly related to the metabolism of nutrients during a nutritional assessment.

Choice C rationale

Certain medications can significantly interfere with the absorption, metabolism, and excretion of various nutrients. For example, some drugs can increase nutrient excretion, decrease appetite, or alter the body's ability to utilize vitamins and minerals, directly impacting nutritional status.

Choice D rationale

While some medications can affect memory and thus the accuracy of a 24-hour food recall, the more direct and critical reason for asking about medications during a nutritional assessment is to identify potential drug-nutrient interactions that affect metabolism.

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Correct Answer is D

Explanation

Choice A rationale

Checking gastric residual volume is essential before administering enteral feedings and medications to assess for delayed gastric emptying, which could increase the risk of aspiration. A high residual volume (typically >500 mL or >250 mL on two consecutive checks) may indicate intolerance to the feeding.

Choice B rationale

Turning the client on their left side after administering enteral feedings and medications is not the recommended position. The right lateral decubitus position is preferred as it promotes gastric emptying by allowing gravity to assist the flow of the feeding into the small intestine.

Choice C rationale

Elevating the head of the bed to a 30-45 degree angle during and for at least 30-60 minutes after enteral feedings significantly reduces the risk of aspiration pneumonia. This position utilizes gravity to help keep the feeding within the stomach and prevent reflux into the esophagus and airway.

Choice D rationale

Leaving the client in their position of comfort while feeding them is incorrect. Maintaining an elevated head of bed position (30-45 degrees) is crucial during and after feeding to prevent aspiration, regardless of the client's perceived comfort. A flat or semi-recumbent position increases the risk of regurgitation and subsequent aspiration into the lungs.

A. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth. B. Asymmetry of the breasts is common, but the nurse should verify that this finding is not new. C. Asymmetry of the breast is unusual, and the patient should be referred to a physician. D. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.

Correct Answer is B

Explanation

Choice A rationale

While a sudden and significant asymmetry in breast size or shape could indicate a new issue such as inflammation or a growth and warrants investigation, a slight, long-standing asymmetry is quite common among women. It does not automatically signify a pathological condition.

Choice B rationale

It is a well-established fact that many women have some degree of natural asymmetry in their breast size and shape. However, it is crucial for the nurse to ascertain if this finding is new for the patient. A recent change in asymmetry could be a sign of a developing condition that requires further evaluation.

Choice C rationale

While any new or significant asymmetry should be evaluated by a physician to rule out underlying issues, a long-standing, slight asymmetry is a common physiological variation and does not necessarily require immediate referral unless other concerning signs or symptoms are present.

Choice D rationale

Breastfeeding can sometimes cause temporary changes in breast size due to milk production and engorgement, and one breast might produce slightly more milk than the other. However, a noticeable and persistent asymmetry might predate breastfeeding or persist beyond it, and while it might be benign, attributing it solely to breastfeeding without further assessment of its history is not prudent. .

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During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the client's spouse about positioning the client to administer his enteral feedings.Which of the following statements indicates the spouse needs further teaching?

Correct Answer is D

Explanation

During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast.Which of these statements is true about this finding?

Correct Answer is B

Explanation

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