A nurse in a long-term care facility is implementing a nutrition plan for a client who is at risk for malnutrition. Which of the following actions should the nurse include in the plan? (Select all that apply.)
Assess for pain prior to mealtime.
Discourage snacks between meals.
Provide mouth care before feeding.
Remove the bedpan from the client's sight.
Administer antiemetics following the meal.
Correct Answer : A,C,D
In a nutrition plan for a client at risk for malnutrition, the nurse should include the following actions:
Assess for pain prior to mealtime: Pain can significantly impact a person's appetite and ability to eat. Assessing for pain before mealtime can help identify any discomfort that may hinder the client's ability to eat.
Provide mouth care before feeding: Proper oral hygiene is essential for maintaining a healthy appetite and preventing oral health issues that can affect eating. Providing mouth care before feeding helps ensure a clean and comfortable oral environment.
Remove the bedpan from the client's sight: Sight and smell can have a significant impact on a person's appetite. Removing the bedpan from the client's sight can help create a more pleasant dining environment and promote a better appetite.
However, the following actions should not be included in the plan:
Discourage snacks between meals: For clients at risk for malnutrition, it may be necessary to encourage nutrient-dense snacks between meals to increase caloric intake. Discouraging snacks may further contribute to malnutrition.
Administer antiemetics following the meal: Administering antiemetics following a meal is not a routine action in a nutrition plan. Antiemetics are typically used to treat nausea and vomiting, which may interfere with a person's ability to eat, but their administration should be based on specific symptoms and prescribed by a healthcare provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The expected finding in an older adult client with dysphagia and dehydration is tachycardia. Tachycardia, an increased heart rate, is a common finding in dehydration as the body tries to compensate for the decreased fluid volume.
The other choices (hypertension, distended neck veins, and decreased respiratory rate) are not typically associated with dehydration in this context.
here's an explanation of why these choices are incorrect:
1. Hypertension: Dehydration usually leads to a decrease in blood volume, resulting in low blood pressure rather than hypertension. Hypertension is not a typical finding in dehydration.
2. Distended neck veins: Dehydration causes a decrease in blood volume, which results in decreased venous return to the heart. Consequently, distended neck veins would not be an expected finding.
3. Decreased respiratory rate: Dehydration itself does not directly affect respiratory rate. However, severe dehydration can lead to electrolyte imbalances, such as hyponatremia (low sodium levels), which can affect brain function and potentially lead to changes in respiratory rate. However, decreased respiratory rate is not a common finding in dehydration alone.
It's important to remember that dehydration can have various signs and symptoms, including dry mucous membranes, decreased urine output, increased thirst, dry skin, dizziness, and confusion.
Correct Answer is A
Explanation
In type 1 diabetes mellitus, when blood glucose levels are consistently high, the body may start breaking down fat for energy, leading to the production of ketones. Ketones can be detected in urine as a result. A blood glucose level of 190 milligrams per deciliter is elevated and can potentially trigger the production of ketones. Monitoring urine for ketones can be an important indicator of diabetes management and helps identify potential complications.
The other statements by the client indicate a lack of understanding or potential misconceptions:
● "I will keep my blood glucose levels between 200 and 212 milligrams per deciliter": This statement suggests a target range that is higher than the recommended target blood glucose levels for individuals with diabetes. Generally, the target range for blood glucose levels in individuals with diabetes is lower, typically between 80-130 mg/dL before meals and below 180 mg/dL after meals.
● "Albumin in my urine is an indication of normal kidney function": This statement is incorrect. The presence of albumin in the urine, called albuminuria, is an indication of kidney damage or dysfunction. It is a common sign of kidney disease, including diabetic nephropathy, which is a complication of diabetes affecting the kidneys.
● "I will keep my HbA1c at five percent": While maintaining a lower HbA1c level is generally desirable for individuals with diabetes, a target of five percent is too low. HbA1c is a measure of average blood glucose levels over the past two to three months. The American Diabetes Association (ADA) recommends an HbA1c target of less than 7 percent for most adults with diabetes, although individualized targets may vary based on factors such as age and other health conditions.
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