A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?
Ask the client's closest kin to convince him to stop fasting due to his injuries.
Encourage the client to stop fasting, as it will delay the wound healing process.
Call dietary to reschedule the client's meals.
Start enteral tube feedings if the client refuses to take food orally.
The Correct Answer is D
Choice A rationale:
Asking the client's closest kin to convince him to stop fasting due to his injuries is not an appropriate action. Respecting the client's religious beliefs and practices is crucial, and attempting to persuade the client to stop fasting would infringe upon their autonomy and cultural values.
Choice B rationale:
Encouraging the client to stop fasting goes against respecting the client's religious observance and autonomy. The nurse should prioritize culturally competent care and support the client in their religious practices, while also ensuring their nutritional needs are met.
Choice C rationale:
Calling dietary to reschedule the client's meals might seem like a reasonable action, but it does not address the client's religious needs or their wound healing process. Ramadan fasting is an important religious practice, and the nurse should find a way to accommodate the client's fasting while also ensuring appropriate nutritional support.
Choice D rationale:
Starting enteral tube feedings if the client refuses to take food orally is the correct action. Beneficence, a principle of ethical nursing care, emphasizes promoting the well-being of the patient. In this case, the nurse should prioritize the client's wound healing by ensuring they receive necessary nutrition through enteral feeding while still respecting their fasting during Ramadan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Dyspnea (shortness of breath) is a common finding in clients with emphysema. Emphysema is a chronic obstructive pulmonary disease characterized by the destruction of lung tissue, leading to reduced lung elasticity and airflow limitation, which can result in difficulty breathing.
Choice B rationale:
Clubbing of the fingers is another expected finding in clients with advanced emphysema. Clubbing is the swelling and rounding of the fingertips, often associated with chronic respiratory conditions. It is thought to be a result of chronic hypoxia and inadequate oxygenation.
Choice C rationale:
Deep respirations are not typically associated with emphysema. Clients with emphysema often exhibit shallow, rapid respirations due to the loss of lung tissue elasticity, which impairs the normal respiratory mechanics.
Choice D rationale:
Bradycardia (slow heart rate) is not a common finding in emphysema. Emphysema primarily affects the respiratory system and does not directly influence heart rate. Bradycardia could be related to other factors but is not a characteristic finding of emphysema.
Choice E rationale:
Barrel chest is a classic physical finding in clients with emphysema. It results from the hyperinflation of the lungs due to the trapping of air in the damaged alveoli. This gives the chest a rounded appearance, similar to the shape of a barrel.
Correct Answer is C
Explanation
A. The left fifth intercostal space at the midclavicular line is the location for palpating the apical pulse, not the pulmonic area. This area is used to assess the heart's apex, particularly for detecting the point of maximal impulse (PMI).
B. The left fifth intercostal space is also associated with the apical pulse, but it lacks the specificity of the midclavicular line, making it less precise for identifying the pulmonic area.
C. The left second intercostal space is the correct location for palpating the pulmonic area. This area is where the pulmonic valve is best auscultated and palpated, allowing for the detection of any abnormal pulsations or sounds related to the pulmonary artery.
D. The right second intercostal space is the location for palpating the aortic area, not the pulmonic area. This site is used to assess the aortic valve and any related abnormalities.
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