A female client with haemorrhoids tells the nurse that she understands the need to avoid eating nuts and seeds to prevent inflammation. How should the nurse respond?
Explain the benefits of a high fibre diet.
Confirm that these foods should be avoided.
Encourage soft foods such as yogurt.
Suggest that the client also avoid fruit skins.
The Correct Answer is B
Choice A
Explain the benefits of a high fibre diet is not correct response. While a high fibre diet can indeed be beneficial for individuals with haemorrhoids by promoting regular bowel movements and reducing strain during defecation, the immediate concern here is addressing the client's understanding about avoiding nuts and seeds. This information could be provided as a follow-up after confirming the client's understanding in response to option B.
Choice B
Confirm that these foods should be avoided is the correct response. In this situation, the nurse's first response should be to confirm the client's understanding and provide accurate information about the need to avoid certain foods. Nuts and seeds can be challenging to digest and may lead to irritation and inflammation in individuals with haemorrhoids. Confirming the client's understanding and providing guidance aligns with the nurse's role in patient education and care.
Choice C
Encourage soft foods such as yogurt is not the correct response. Encouraging soft foods like yogurt is a reasonable suggestion for someone with haemorrhoids, as soft foods are generally easier to digest and less likely to cause irritation. However, the client's statement was specifically about avoiding nuts and seeds. While this choice might be relevant, it doesn't directly address the client's statement.
Choice D
Suggest that the client also avoid fruit skins is not the correct response. This option is not directly related to the client's concern about nuts and seeds. Fruit skins generally contain dietary fibre, which can be beneficial for maintaining regular bowel movements. While some individuals might find that certain fruits with tough skins could exacerbate their haemorrhoid symptoms, this advice might be better suited for a separate discussion about dietary choices rather than as a direct response to the client's statement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A
Low residue diet is incorrect. A low residue diet is typically recommended for individuals with gastrointestinal conditions like inflammatory bowel disease or diverticulitis. This diet limits high-fibre foods to reduce bowel movements and ease digestive stress. However, it might not be the best option for a client with stomatitis who is struggling to eat due to mouth pain.
Choice B
Mechanical soft diet is incorrect. A mechanical soft diet includes foods that are soft and easy to chew, but they aren't necessarily pureed. While this diet might be more comfortable to eat for some individuals, a client with severe stomatitis might still experience pain while chewing. A pureed diet is a step further in terms of texture modification and can be better tolerated by someone with significant mouth pain.
Choice C
Pureed regular diet is correct. Stomatitis is inflammation of the mouth and can cause pain and discomfort, making it difficult for the client to eat. In this case, a pureed regular diet would be the most suitable choice.
Choice D
High protein soft diet is incorrect. While a high protein diet is important for recovery, healing, and maintaining muscle mass, the texture of the diet is equally important for someone with stomatitis. A high protein soft diet might still involve foods that are challenging to eat due to mouth pain, and therefore, a pureed diet would be a better option in this case.
Correct Answer is A
Explanation
Choice A
Demonstrating correct measurement of the tube insertion length is the first priority. Inserting a nasogastric tube to the appropriate length is crucial for ensuring that the tube reaches the stomach and is not inserted too far. Incorrect insertion length can lead to complications, discomfort, or potential harm to the patient. Therefore, demonstrating and ensuring the correct measurement of the tube insertion length takes priority.:
Choice B
Reminding the nurse to apply lubricant to the tube before insertion is not first priority. Applying lubricant helps ease the insertion process, but it is not the most critical step to prioritize initially.
Choice C
Confirming that the nurse has auscultated the client's bowel sounds is not the first priority. Bowel sounds assessment is important to ensure proper placement, but this step can be done after ensuring the correct measurement of the insertion length.
Choice D
Elevating the head of the bed before the nurse inserts the tube is not the first priority: Elevating the head of the bed helps facilitate the passage of the tube into the stomach, but it is not the first priority in this context.
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