The nurse is assessing the nutritional status of several clients. Which client has the greatest risk for health problems related to nutritional deficits?

An 89-year-old stroke victim with a fractured hip and dysphagia.

An obese 42-year-old male admitted for a hernia repair.

A woman at 4-weeks gestation suffering from morning sickness.

A 6-year-old who had a tonsillectomy yesterday.

Answer and Explanation

The Correct Answer is A

A. An 89-year-old stroke victim with a fractured hip and dysphagia is at the greatest risk for nutritional deficits. Dysphagia, or difficulty swallowing, can severely limit the intake of essential nutrients, leading to malnutrition. Additionally, the advanced age and the physical trauma from the stroke and hip fracture further increase the risk of nutritional deficiencies and related health problems.

B. An obese 42-year-old male admitted for a hernia repair may have nutritional concerns, but obesity itself does not necessarily indicate a risk for nutritional deficits. While obesity can be associated with poor dietary habits, it does not inherently mean the individual is lacking essential nutrients.

C. A woman at 4-weeks gestation suffering from morning sickness may experience temporary nutritional challenges due to nausea and vomiting. However, this condition is usually transient and can be managed with dietary adjustments and medical advice, making it less critical compared to the other options.

D. A 6-year-old who had a tonsillectomy yesterday might have temporary dietary restrictions due to post-surgical pain and discomfort. However, this is typically a short-term issue and does not pose a long-term risk for nutritional deficits.

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Correct Answer is ["B"]

Explanation

Choice B reason:

Asking the client about medical problems that could possibly cause indigestion is the first step the nurse should take. Indigestion can be a symptom of various underlying medical conditions, such as gastroesophageal reflux disease (GERD), peptic ulcers, or even cardiac issues. Understanding the client’s medical history helps identify any serious conditions that need to be addressed before considering herbal remedies. This approach ensures that the nurse provides safe and appropriate care based on the client’s overall health status.

Choice A reason:

Referring the client to the dietician for information on other herbal supplements can be helpful, but it should not be the first step. It is important to first understand the client’s medical history and current health status to ensure that any recommendations are safe and appropriate.

Choice C reason:

Validating the client’s consideration of mint products for minimizing indigestion is supportive, but it should come after assessing the client’s medical history. While peppermint can help with indigestion, it may not be suitable for all clients, especially those with certain medical conditions.

Choice D reason:

Reviewing the client’s dietary intake that may precipitate the indigestion episodes is important, but it should follow the assessment of the client’s medical history. Identifying dietary triggers is useful, but understanding the overall health context is crucial for providing comprehensive care.

A. Chicken. B. Cherries. C. Hard salami. D. Whole wheat bread.

Correct Answer is C

Explanation

Choice C reason:

Hard salami is high in tyramine, a compound that can trigger migraine headaches in susceptible individuals. Tyramine is found in aged, fermented, and cured foods, and it can cause blood vessels to constrict and then dilate, leading to migraines. Eliminating hard salami from the diet can help reduce the frequency and severity of migraine headaches for those who are sensitive to tyramine.

Choice A reason:

Chicken is low in tyramine and is generally safe for individuals trying to avoid this compound. It is a good source of protein and can be included in a diet aimed at reducing migraine triggers.

Choice B reason:

Cherries are low in tyramine and do not typically trigger migraines. They are a healthy fruit option that can be included in the diet without increasing the risk of headaches.

Choice D reason:

Whole wheat bread is also low in tyramine and is a good source of fiber and nutrients. It does not pose a risk for triggering migraines and can be safely included in the diet.

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The nurse is assessing the nutritional status of several clients. Which client has the greatest risk for health problems related to nutritional deficits?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who reports frequent indigestion asks the nurse if using an herbal preparation of peppermint might help alleviate the indigestion. Which response should the nurse do first?

Correct Answer is ["B"]

Explanation

A client who has migraine headaches wants to decrease the intake of foods high in tyramine to see if that will reduce the occurrence of headaches. Which food should the nurse recommend that the client eliminate?

Correct Answer is C

Explanation

The nurse is caring for an older adult client who needs to limit sodium intake. Which food should the nurse encourage the client to avoid?

When conducting diet teaching for a client who was diagnosed with iron-deficiency anemia, what food(s) should the nurse encourage the client to eat? Select all that apply.

A nurse is planning care for several clients. Which client(s) are at an increased risk for malnutrition? Select all that apply.

A client who is training for a first marathon arrives at the clinic reporting an increase in the frequency of leg cramps. Which recommendation should the nurse provide to help decrease the frequency of leg cramps?

A healthcare provider inserts a subclavian central venous catheter (CVC) and prescribes total parenteral nutrition (TPN) for infusion via the line. While waiting for the pharmacy to deliver the TPN, which action should the nurse take?

A clear liquid breakfast is prescribed for a client who is scheduled for surgery later today. The client asks the nurse for a small cup of chocolate ice cream. Which action should the nurse take?

A client with glomerulonephritis is preparing for discharge and asks the nurse which kind of diet to follow upon return. Which dietary teaching should the nurse include in the discharge instructions?