A client is to receive enteral nutrition. Which information should the nurse provide to the client and family? (SELECT ALL THAT APPLY)
"Enteral nutrition may be used in addition to or instead of oral intake."
"Most enteral nutrition consists of thinned pureed food."
"Enteral nutrition can be given either intermittently or continuously."
"Enteral nutrition is milk based."
"Enteral nutrition can be given through a vein."
Correct Answer : A,C
A. Enteral nutrition can be used when a client is unable to consume adequate nutrition orally or when oral intake is contraindicated. It can be used as a supplement to oral intake or as the sole source of nutrition, depending on the client's condition and nutritional needs.
C. Enteral nutrition can be administered either intermittently, where feedings are given at specific times throughout the day, or continuously, where a steady infusion is delivered over an extended period, typically 16 to 24 hours. The method of administration depends on the client's tolerance, nutritional needs, and clinical condition.
B. Enteral nutrition typically consists of liquid formulas specifically designed to provide complete and balanced nutrition. These formulas come in various formulations, including standard polymeric formulas, high-protein formulas, elemental formulas, and disease-specific formulas. They are not thinned pureed food, which is typically used for clients with dysphagia or swallowing difficulties who are receiving oral feeding.
D. While some enteral nutrition formulas may contain dairy-based ingredients, such as milk protein or lactose, not all enteral formulas are milk-based. There are various types of enteral formulas available, including those that are lactose-free, soy-based, or elemental (containing predigested nutrients), to accommodate different dietary preferences and tolerances.
E. Enteral nutrition is administered directly into the gastrointestinal tract, typically through a feeding tube that is inserted into the stomach or small intestine. It is not given intravenously (through a vein), which would be parenteral nutrition.
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Related Questions
Correct Answer is C
Explanation
C. Assisting the client in slowed breathing techniques is the most appropriate initial intervention for a client experiencing hyperventilation due to acute psychological stress. Slowed breathing techniques, such as pursed-lip breathing or diaphragmatic breathing, can help normalize respiratory rate and depth, thereby correcting the respiratory alkalosis. Encouraging the client to breathe slowly and deeply can help reduce the respiratory rate and restore a more balanced acid-base status.
A. Administering a sedative may not be the initial intervention for a client experiencing hyperventilation due to acute psychological stress. Sedatives can depress the respiratory drive further and may exacerbate respiratory alkalosis. Additionally, administering sedatives should be based on a comprehensive assessment and medical prescription, rather than as a first-line intervention for hyperventilation.
B. While hyperventilation can sometimes lead to symptoms resembling seizure activity (such as muscle twitching or numbness), assessing for seizure activity is not typically the initial intervention for respiratory alkalosis. In the context of acute psychological stress causing hyperventilation, addressing the hyperventilation itself is the priority.
D. While monitoring vital signs, including blood pressure, is important in assessing the client's overall condition, it is not the initial intervention specifically for addressing respiratory alkalosis due to hyperventilation. The priority in this situation is to address the hyperventilation itself through appropriate breathing techniques.
Correct Answer is D
Explanation
D. Denial is often the initial stage of the grieving process, characterized by disbelief or avoidance of the reality of the situation. Clients may refuse to accept the diagnosis or its implications, clinging to the hope that it is not true. The client's statement of "This cannot be happening to me" is consistent with denial, as they are expressing disbelief or resistance to the reality of their diagnosis.
A. This stage involves feelings of sadness, despair, and hopelessness. While depression is a common response to a terminal diagnosis, the client's statement of "This cannot be happening to me" suggests that they may still be in an earlier stage of grief.
B. Anger is another common stage of the grieving process, characterized by feelings of frustration, resentment, and hostility. Clients may direct their anger towards themselves, others, or even a higher power. While anger can be a prominent reaction to a terminal diagnosis, the client's statement does not explicitly express anger but rather disbelief or resistance.
C. Bargaining is a stage in which individuals may attempt to negotiate or make deals in an effort to change or postpone the inevitable outcome. For example, a client may pray for more time or promise to change their behavior in exchange for a better outcome. The client's statement of "This cannot be happening to me" does not reflect bargaining but rather denial or disbelief.

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