Exhibits

Review H and P, nurse's notes, flow sheet, laboratory values, prescriptions, and imaging studies.

Highlight the times that the practical nurse (PN) should measure vital signs.

A. 1000

B. 1200

C. 1500

D. 1400

E. 1800

F. 1600

G. 2000

H. 0800

• 1. 21 to 24%: The client’s fat intake for the three days totals approximately 69 grams of fat (24g + 22g + 23g), which, when multiplied by 9 calories per gram, equals about 621 calories from fat. Given the total caloric intake of 3,200–3,310 calories per day, fat constitutes approximately 21% to 24% of the total caloric intake, which is within the recommended range for a balanced diet.
• 2. has an appropriate fat intake for calories: The fat intake of 21% to 24% of total calories aligns with the general dietary recommendation, which is for 20% to 35% of total calories to come from fat. Therefore, the client’s fat intake is appropriate and does not require any adjustments.

• 1. 26 to 28%: This percentage would be too high for the client’s daily fat intake. To reach 26% to 28% of calories from fat, the client would need to consume more grams of fat. Based on the actual fat intake (69g), this range is not appropriate.
• 1. 14 to 19%: A fat intake of 14% to 19% would be considered lower than the recommended range, and would suggest the client is consuming too little fat for a balanced diet. Given the actual fat intake, this percentage is not accurate.
• 2. should increase his fat intake: Given that the client’s fat intake is already within the recommended 20%–35% range, there's no need for the client to increase his fat intake. Therefore, this option is not appropriate.
• 2. should reduce his fat intake: Reducing the client’s fat intake is not necessary, as the fat intake falls within the recommended range. A reduction in fat would lower the total percentage of calories from fat below the suggested 20%–35% range, which could be harmful for overall nutrition.
• 2. should decrease his caloric intake: There’s no indication that the client is consuming an excessive amount of calories based on the information provided. His calorie intake seems appropriate for his needs. Decreasing caloric intake isn't necessary, especially when his fat intake is within the normal range.

A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.