A nurse is caring for a client who is malnourished. The client states, "When I do eat, I usually just eat bread and butter to get someth“ng in me." The nurse should recognize that the client is a risk for which ”f following complications?
Gastroesophageal reflux disease
Diabetes mellitus
Heat intolerance
Pressure injury
The Correct Answer is D
A) Gastroesophageal reflux disease (GERD): While a diet primarily consisting of bread and butter may contribute to GERD in some individuals due to its high-fat content and potential for triggering reflux symptoms, pressure injuries are a more immediate concern in a malnourished client. GERD typically manifests with symptoms such as heartburn, regurgitation, and chest pain, rather than pressure injuries.
B) Diabetes mellitus: Although poorly controlled diabetes can lead to impaired wound healing and increase the risk of pressure injuries, the primary concern in a malnourished client with limited dietary intake is the development of pressure injuries due to compromised skin integrity and tissue breakdown. While diabetes management is essential for overall health, it is not the immediate risk in this scenario.
C) Heat intolerance: Malnutrition can contribute to various metabolic imbalances and complications, but heat intolerance is not a common consequence of limited dietary intake alone. While malnutrition may exacerbate existing conditions, such as hyperthyroidism, leading to heat intolerance, pressure injuries are more directly linked to inadequate nutrition and skin breakdown.
D) Pressure injury: Inadequate nutrition, particularly a diet primarily consisting of bread and butter, lacks essential nutrients needed for tissue repair and skin integrity maintenance. This puts the client at significant risk for developing pressure injuries, especially over bony prominences, due to prolonged pressure on the skin. Pressure injuries are a common complication in malnourished individuals and can lead to further complications, including infection and delayed wound healing. Therefore, in this scenario, the client's limited dietary intake poses the greatest risk for pressure in’uries.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A) Remove the bedpan from the client's sight: This action is not directly related to addressing malnutrition. While it may improve the client's comfort and environment, it does not contribute directly to addressing nutritional needs.
B) Provide mouth care before feeding: This action is appropriate. Ensuring good oral hygiene, including mouth care before meals, can stimulate the appetite and enhance the client's ability to taste and enjoy food. It also helps prevent infections and discomfort associated with poor oral hygiene.
C) Assess for pain prior to mealtime: This action is essential. Pain can significantly affect a client's appetite and ability to eat. By assessing for pain before mealtime, the nurse can identify any discomfort that might interfere with the client's ability to consume food and address it promptly.
D) Administer antiemetics following the meal: While antiemetics may be necessary for some clients who experience nausea or vomiting during or after meals, their administration should be based on individual assessment and prescription by a healthcare provider. Routine administration of antiemetics following meals is not standard practice and may not be appropriate for all clients.
Correct Answer is D
Explanation
A) Breastfeeding alone cannot prevent a baby from developing phenylketonuria (PKU). PKU is an inherited metabolic disorder characterized by the body's inability to process phenylalanine, an amino acid found in protein. Infants with PKU must follow a special low-phenylalanine diet from birth to prevent intellectual disability and other complications. Breast milk contains phenylalanine, so infants with PKU require a special formula that is low in phenylalanine.
B) The consumption of diet sodas is not directly related to the management of phenylketonuria (PKU). Clients with PKU must closely monitor their intake of phenylalanine, an amino acid found in protein-containing foods. Diet sodas typically do not contain protein or phenylalanine, so their consumption is not a primary concern for individuals with PKU.
C) Monitoring serum bilirubin levels is not specific to the management of phenylketonuria (PKU) during pregnancy. Serum bilirubin levels are typically monitored to assess liver function and screen for conditions such as jaundice. While individuals with PKU may require additional monitoring during pregnancy, such as monitoring phenylalanine levels, serum bilirubin levels are not typically a focus of PKU management.
D) Following a low-protein diet for several months prior to conception is an important aspect of managing phenylketonuria (PKU) during pregnancy. High levels of phenylalanine in the mother's blood can cross the placenta and harm the developing fetus, potentially leading to intellectual disability and other complications. By adhering to a low-protein diet before conception, individuals with PKU can lower their phenylalanine levels and reduce the risk of complications during pregnancy.
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