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A nurse in an outpatient clinic is caring for a client

Vital Signs
BP 124/68 mm Hg
Heart rate 80/min

Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

Which of the following statements should the nurse include in the client's teaching?

Select all that apply.

Try using an abdominal support belt

Take hot showers to help relieve itching"

"Wear loose-fitting clothing"

"Eat two large meals a day."

You should avoid fried foods"

Answer and Explanation

Correct Answer : C,D,G

Choice A reason:

"Try using an abdominal support belt". This statement is incorrect. There is no indication or relevance for using an abdominal support belt based on the vital signs and weight provided. This statement is not appropriate for the client's teaching.

Choice B reason:

"Take hot showers to help relieve itching" This statement is incorrect. Itching is not mentioned in the vital signs and weight provided. Additionally, taking hot showers might not be relevant to the client's condition or needs. This statement is not appropriate for the client's teaching.

Choice C reason:

"Wear loose-fitting clothing" This is an appropriate statement for the client's teaching. Wearing loose-fitting clothing can provide comfort and allow better circulation, which might be helpful for some clients.

Choice D reason:

"Wear flat or low-heeled shoes" This is an appropriate statement for the client's teaching. Wearing flat or low-heeled shoes can help provide comfort and support, especially if the client has any foot or back issues.

Choice E reason:

"You can douche twice weekly." Douche is not relevant to the vital signs and weight provided, and it is generally not recommended for routine use as it can disrupt the natural balance of vaginal flora. This statement is not appropriate for the client's teaching.

Choice F reason:

"Eat two large meals a day." This statement does not align with a healthy eating pattern, and it might not be appropriate for the client's health needs. The recommendation for a balanced diet usually includes several smaller meals throughout the day. This statement is not appropriate for the client's teaching.

Choice G reason:

"You should avoid fried foods." This is an appropriate statement for the client's teaching. Avoiding fried foods can be beneficial for overall health, especially if the client is trying to manage weight or maintain a balanced diet.

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Correct Answer is C

Explanation

Choice A rationale:

Overweight is not applicable in this situation as the client's BMI indicates a weight status below the normal range.

Choice B rationale:

Obesity class 1 is not applicable in this situation as the client's BMI indicates a weight status below the normal range.

Choice C rationale:

Underweight is the correct choice. A BMI of less than 18.5 is considered underweight according to the World Health Organization (WHO) classification. A BMI of 17.2 falls below this threshold, indicating that the client is underweight. This is a cause for concern, as individuals with Crohn's disease often struggle with maintaining a healthy weight due to malabsorption issues and reduced appetite.

Choice D rationale:

Healthy weight is not applicable in this situation as the client's BMI is below the normal range, indicating an underweight status.

A. Measure gastric residual volumes every 4 hr. B. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication. C. Maintain the head of the bed at a 20° angle. D. Advance the rate of the feeding every 2 hr.

Correct Answer is A

Explanation

A. Correct. Measuring gastric residual volumes every 4 hours is important to assess gastric emptying and to determine if the client can tolerate the feedings. If residuals are high, it may indicate delayed gastric emptying and the need to adjust the feeding rate.

B. Incorrect. While flushing the NG tube before and after medications is important to maintain patency, it is typically done with sterile water, not sodium chloride, unless otherwise specified by a protocol. Therefore, this statement may not be fully accurate.

C. Incorrect. The head of the bed should be elevated to a 30-45° angle to help prevent aspiration during enteral feedings.

D. Incorrect. The rate of the feeding should be advanced gradually to prevent overloading the client's gastrointestinal tract. This does not involve advancing the rate every 2 hours.

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A nurse in an outpatient clinic is caring for a client Vital Signs BP 124/68 mm Hg Heart rate 80/min Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Crohn's disease.The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

Correct Answer is C

Explanation

A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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A nurse is assessing a 24-month-old toddler at a well-child checkup.Which of the following findings indicates to the nurse that the toddler has developmental delay?

A client with Crohn's disease is preparing for discharge from the hospital following treatment for an exacerbation of diarrhea, abdominal pain, and rectal bleeding. Which dietary recommendation(s) should the nurse discuss with the client? (Select all that apply.)

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A nurse in an outpatient clinic is caring for a client

Vital Signs
BP 124/68 mm Hg
Heart rate 80/min

Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)