A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
Encourage three large meals daily.
Administer an antiemetic after each meal.
Season foods with spices.
Provide a high-calorie diet.
The Correct Answer is D
Choice A Reason:
Encouraging three large meals daily might not be feasible for someone experiencing malnutrition and decreased appetite. Smaller, more frequent meals or snacks throughout the day could be better tolerated and more beneficial.
Choice B Reason:
Administering an antiemetic after each meal assumes that the client will experience nausea or vomiting regularly after eating. This might not be the case for all clients with AIDS and may not be necessary if the primary issue is malnutrition without associated frequent vomiting.
Choice C Reason:
Seasoning foods with spices might improve the taste of food and potentially stimulate appetite, but it's not as direct or comprehensive a measure for addressing malnutrition as providing a high-calorie diet.
Choice D Reason:
Provide a high-calorie diet is correct. Clients with AIDS often experience malnutrition due to various factors such as decreased appetite, difficulty eating, or malabsorption. Offering a high-calorie diet can help address nutritional deficiencies and support the body's increased energy needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Maintaining skin integrity over the blisters is correct. Blisters form as a protective mechanism for the skin underneath. Popping or breaking blisters increases the risk of infection as it exposes the raw skin to bacteria and other contaminants.
Choice B Reason:
Applying ice to the larger blisters is incorrect.
Reason: Applying ice directly to a burn, especially to blisters, can further damage the skin and exacerbate the injury. Ice can cause additional skin damage and can potentially increase pain and delay healing.
Choice C Reason:
Administering ibuprofen for pain is correct. Ibuprofen is an effective over-the-counter pain reliever that can help manage the discomfort caused by a minor burn. It also has anti-inflammatory properties that can reduce swelling associated with burns.
Choice D Reason:
Running cool water over the affected area is correct. Running cool (not cold) water over the burn helps to cool down the burned area, soothes the pain, and helps prevent further damage to the skin. It's recommended to run water over the burn for around 10-15 minutes to effectively cool the area.
Choice E Reason:
Allowing the affected area to remain open to air is incorrect. Keeping a minor burn uncovered can increase the risk of infection as it exposes the burn to external contaminants. Covering the burn with a sterile, non-stick dressing can protect it from further damage and reduce the risk of infection.
Correct Answer is C
Explanation
Choice A Reason:
“I'm going to take your heart rate”. This statement is incorrect. Monitoring vital signs like heart rate is essential in assessing a client's condition. However, in this scenario, the client's report of hives, itching, and a potential allergic reaction is more indicative of an immediate concern for anaphylaxis. While monitoring heart rate is relevant, assessing for signs of anaphylaxis, especially difficulty breathing, takes precedence due to the urgency of potential respiratory distress.
Choice B Reason:
"I need to give you diphenhydramine". This statement is incorrect, administering an antihistamine like diphenhydramine can help alleviate allergic symptoms, including itching and hives. However, confirming the severity of the reaction and ensuring there are no life-threatening symptoms such as breathing difficulties is the immediate priority before administering any medication.
Choice C Reason:
"Are you having difficulty breathing?" This statement is correct. This question directly assesses the client's respiratory status, a crucial indicator of anaphylaxis. If the client is experiencing difficulty breathing, it indicates a severe allergic reaction that requires immediate intervention and emergency medical attention. Recognizing and addressing potential respiratory distress is of utmost importance in managing an allergic reaction to medication.
Choice D Reason:
"Do you have any allergies to medications? This statement is incorrect. Understanding the client's medical history, including allergies, is crucial. However, in this acute situation where the client is already experiencing symptoms of a potential allergic reaction shortly after receiving penicillin, addressing the current symptoms and assessing for signs of anaphylaxis is the most immediate concern.
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