A nurse is assisting in the care of a client who is malnourished and states, ‘’I refuse to eat right now. It goes against my beliefs.’’ Which of the following responses should nurse make?

If you continue to refuse to eat, I will have to insert an NG tube

Why aren't you willing to eat?

"Your nutrition is more important than your beliefs.

Let's discuss some menu options you would be interested in."

Answer and Explanation

The Correct Answer is D

A) If you continue to refuse to eat, I will have to insert an NG tube: This response is coercive and may not be respectful of the client’s autonomy. It can create a sense of fear and mistrust, which can make the client feel pressured or cornered. It is important to respect the client’s beliefs and preferences while also promoting nutrition, so alternative options should be explored in a more collaborative manner.

B) Why aren't you willing to eat?: While it’s important to understand the client’s reasons for refusing to eat, this response could come across as confrontational. It may place the client on the defensive and fail to acknowledge their beliefs and autonomy. A more open-ended and supportive approach is needed to create a dialogue that is respectful and patient-centered.

C) "Your nutrition is more important than your beliefs.": This response disregards the client's personal beliefs and could be perceived as disrespectful. While nutrition is critical, it is important to work within the framework of the client’s values and beliefs. The nurse should strive for a compassionate conversation that balances nutritional needs with cultural or personal beliefs.

D) Let's discuss some menu options you would be interested in.: This response is respectful of the client’s beliefs and autonomy while still addressing the issue of malnutrition. By offering options and engaging the client in the decision-making process, the nurse fosters a collaborative approach. This can help increase the likelihood of the client agreeing to eat while respecting their preferences and beliefs.

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Correct Answer is ["C","E"]

Explanation

A. Encourage prolonged dangling before ambulation.
Prolonged dangling is not necessary for this client, who is already ambulating independently. Extended dangling may increase the risk of orthostatic hypotension without providing significant benefits.

B. Administer an enema.
An enema is not the first-line intervention for postoperative constipation. The client has had a bowel movement, albeit small and painful, so increasing fluids and noninvasive measures like a sitz bath should be attempted first.

C. Encourage oral fluid intake.
Adequate hydration helps soften stool and prevent constipation, a common postoperative concern. The client’s fluid intake should be increased to support bowel function and improve urinary output.

D. Irrigate indwelling catheter with 500 mL of fluid.
The client has pink urine but is maintaining an adequate output of 100 mL/hr. Routine catheter irrigation is unnecessary unless there is evidence of obstruction, such as decreased urine flow or clot formation.

E. Assist the client with a sitz bath.
A sitz bath can provide comfort by promoting relaxation of perineal muscles, reducing pain during bowel movements, and improving circulation to the surgical site, which may aid healing.

A. Social withdrawal B. Wandering outside at night C. Difficulty articulating words D. Inability to remember their partner's name

Correct Answer is B

Explanation

A) Social withdrawal: While social withdrawal can be a sign of depression or a worsening cognitive decline in clients with Alzheimer's disease, it does not immediately threaten the client's safety. It is important to monitor and address, but it is not the priority concern that requires immediate intervention.

B) Wandering outside at night: This is the priority issue and requires immediate intervention. Wandering, especially at night, poses a significant safety risk to clients with Alzheimer's disease. The client may become lost, disoriented, or fall, leading to injury. Immediate steps should be taken to ensure the environment is safe, such as installing locks or alarms on doors, and potentially seeking further evaluation or care interventions to manage this behavior.

C) Difficulty articulating words: Difficulty with speech or articulation can occur as part of Alzheimer's disease, especially in the later stages. While it can be distressing for the client and family, it does not present an immediate threat to the client's safety. This issue should be addressed as part of the overall care plan, but it is not as urgent as wandering.

D) Inability to remember their partner's name: Memory loss, including difficulty remembering names, is a common symptom of Alzheimer's disease. While it can be emotionally difficult for both the client and their family, it does not pose an immediate risk to the client’s safety or well-being. This symptom should be monitored, but it is not the top priority for immediate intervention.

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A nurse is assisting in the care of a client who is malnourished and states, ‘’I refuse to eat right now. It goes against my beliefs.’’ Which of the following responses should nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select the 2 actions the nurse should prepare to take for the client.

Correct Answer is ["C","E"]

Explanation

A nurse is collecting data from the family members of a client who has Alzheimer's disease. Which of the following findings should the nurse identify is the priority and requires immediate intervention?

Correct Answer is B

Explanation

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