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)
Administer antiemetics following the meal.
Provide mouth care before feeding.
Assess for pain prior to mealtime.
Remove the bedpan from the client's sight.
Discourage snacks between meals.
Correct Answer : B,C,D
Choice A reason: Administering antiemetics following the meal is not an appropriate action for a client who is at risk for malnutrition. Antiemetics are medications that prevent or treat nausea and vomiting, which can interfere with oral intake and hydration. However, antiemetics should be given before the meal, not after, to reduce the likelihood of postprandial nausea and vomiting. ¹²
Choice B reason: Providing mouth care before feeding is an appropriate action for a client who is at risk for malnutrition. Mouth care can improve the client's appetite, taste, and comfort, as well as prevent oral infections and dental problems that can affect food intake. ³⁴
Choice C reason: Assessing for pain prior to mealtime is an appropriate action for a client who is at risk for malnutrition. Pain can reduce the client's appetite, mood, and ability to eat comfortably. The nurse should assess the client's pain level and provide adequate pain relief before offering food. ⁵⁶
Choice D reason: Removing the bedpan from the client's sight is an appropriate action for a client who is at risk for malnutrition. The presence of a bedpan or other unpleasant stimuli can cause the client to lose appetite, feel nauseated, or associate food with negative emotions. The nurse should create a pleasant and comfortable environment for the client to eat. ⁷⁸
Choice E reason: Discouraging snacks between meals is not an appropriate action for a client who is at risk for malnutrition. Snacks can provide additional calories, protein, and micronutrients that the client may not get from regular meals. Snacks can also help prevent hunger, fatigue, and hypoglycemia between meals. The nurse should encourage the client to have healthy snacks that are high in energy and nutrient density.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice D reason:A metallic taste in the mouth is not a recognized symptom of hyperglycemia. It may occur in other conditions, such as certain medication side effects, infections, or metabolic disorders, but it is not specific to diabetes or high blood glucose levels. Including this as a sign of hyperglycemia could lead to confusion or misinterpretation of symptoms.
Choice A reason: Anxiety is not a specific symptom of hyperglycemia, although it can be associated with stress or other psychological factors that can affect blood sugar levels. Anxiety can also be a symptom of hypoglycemia, or low blood sugar, which requires immediate treatment.
Choice B reason: Hyperventilation, characterized by deep and rapid breathing, is a critical manifestation of severe hyperglycemia, particularly in cases ofdiabetic ketoacidosis (DKA). When blood glucose levels are extremely high, the body may produce ketones, leading to metabolic acidosis. To compensate, the client may developKussmaul respirations, a type of hyperventilation aimed at expelling excess carbon dioxide. This is a medical emergency and requires immediate intervention. Teaching the client to recognize hyperventilation as a sign of severe hyperglycemia is essential for timely treatment and prevention of complications.
Choice C reason: Cool skin is not a symptom of hyperglycemia, but rather a sign of poor circulation, which can be a complication of diabetes. Diabetes can damage the blood vessels and nerves that supply blood and oxygen to the skin, especially in the feet and legs. This can lead to skin problems, infections, and ulcers.
Correct Answer is B
Explanation
Choice A reason: Bran cereal is high in phosphorus, containing about 34% of the DV per cup (118 g) ( 1 ). Phosphorus is a mineral that helps build strong bones and teeth, but too much of it can cause problems for people with kidney disease. The kidneys normally filter out excess phosphorus from the blood, but when they are damaged, phosphorus can build up and cause bone loss, itching, and calcification of blood vessels and organs ( 2 ).
Choice B reason: A medium apple is low in phosphorus, containing only 3% of the DV per 182 g ( 3 ). Apples are also a good source of fiber, vitamin C, and antioxidants. They can help lower blood pressure, cholesterol, and blood sugar levels, which are beneficial for people with kidney disease ( 4 ).
Choice C reason: Scrambled eggs are moderate in phosphorus, containing about 12% of the DV per large egg (50 g) ( 5 ). Eggs are also high in protein, which can increase the workload of the kidneys and worsen kidney function. People with kidney disease should limit their protein intake to 0.8 g per kg of body weight per day, unless advised otherwise by their doctor ( 6 ).
Choice D reason: Ground turkey is high in phosphorus, containing about 16% of the DV per 3 oz (85 g) ( 7 ). Ground turkey is also high in protein, which can have the same negative effects as eggs on kidney function. People with kidney disease should choose lean meats and poultry, and eat them in moderation.
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