A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

Fever.

Visual disturbance.

Gait alteration.

Hypoxia.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Fever is typically regulated by the hypothalamus, a part of the brain that controls body temperature. Dysfunction of the lower brain stem does not typically cause fever.

Choice B rationale

Visual disturbances are often related to issues with the visual cortex or optic pathways, which are not part of the lower brain stem.

Choice C rationale

Gait alteration is typically associated with dysfunction in the cerebellum or motor pathways, rather than the lower brain stem.

Choice D rationale

Hypoxia, or decreased oxygen levels, can be a critical concern with lower brain stem dysfunction as the lower brain stem controls vital autonomic functions such as respiration and heart rate.

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Correct Answer is A

Explanation

Choice A rationale

Potassium-rich foods, such as bananas and potatoes, are recommended for clients with prolonged diarrhea to replace lost electrolytes and maintain normal cellular function.

Choice B rationale

High-fat foods are not recommended for clients with prolonged diarrhea, as they can exacerbate symptoms and are difficult to digest.

Choice C rationale

High-fiber foods may worsen diarrhea by increasing stool bulk and frequency.

Choice D rationale

While protein-rich foods are important, they do not specifically address the electrolyte imbalances caused by prolonged diarrhea.

A. 5% deficit in body weight compared to pre-illness weight and increased caloric need. B. Significant risk of aspiration coupled with decreased level of consciousness. C. Calorie deficit and muscle wasting combined with low electrolyte levels. D. Inability to take in adequate oral food or fluids within 7 days.

Correct Answer is D

Explanation

Choice A rationale

A 5% deficit in body weight and increased caloric need alone do not warrant the initiation of parenteral nutrition (PN). PN is typically reserved for situations where oral or enteral feeding is not feasible or safe.

Choice B rationale

Significant risk of aspiration and decreased level of consciousness may necessitate alternative feeding methods, such as enteral feeding via a nasogastric or gastrostomy tube. PN is considered when enteral feeding is not possible.

Choice C rationale

Calorie deficit, muscle wasting, and low electrolyte levels indicate malnutrition, but PN is initiated when other feeding methods are inadequate or unsafe.

Choice D rationale

Inability to take in adequate oral food or fluids within 7 days is a clear indication for initiating PN. This ensures the patient receives essential nutrients and prevents further deterioration of their nutritional status.

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A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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