A nurse is performing a nutritional screening for a client. Which of the following statements by the client indicates the need for further data collection?

"I eat at least two meals every day and snack frequently."

"I drink 4 ounces of wine with dinner several times each week."

"I take several prescription medications every day."

"I am able to keep my weight steady without gaining or losing."

Answer and Explanation

The Correct Answer is C

A. "I eat at least two meals every day and snack frequently.": Consuming at least two meals daily with additional snacks suggests a relatively consistent caloric intake. While a full dietary recall would still be appropriate, this statement alone does not immediately suggest nutritional risk without evidence of poor food quality or imbalance.

B. "I drink 4 ounces of wine with dinner several times each week.": Moderate alcohol intake, such as 4 ounces of wine with dinner, may not independently indicate nutritional compromise. Although excessive alcohol can interfere with nutrient absorption and metabolism, this amount does not automatically suggest malnutrition without additional risk factors.

C. "I take several prescription medications every day.": Multiple prescription medications raise concern for potential drug–nutrient interactions, altered appetite, gastrointestinal side effects, or impaired absorption of vitamins and minerals. Polypharmacy can also affect taste, swallowing, or metabolic processes, increasing the risk of nutritional deficiencies.

D. "I am able to keep my weight steady without gaining or losing.": Stable weight over time generally suggests adequate caloric intake relative to metabolic needs. Although body composition and diet quality still require evaluation, maintaining weight does not immediately signal nutritional risk in the absence of other concerning findings.

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Correct Answer is B

Explanation

A. Oral irrigating device: An oral irrigating device is used for oral hygiene but is not a priority for a client with bacterial meningitis. Infection control and safety interventions take precedence over routine hygiene equipment upon admission.

B. Seizure pads: Clients with bacterial meningitis are at risk for increased intracranial pressure and seizures due to inflammation of the meninges. Placing seizure pads on the bed helps prevent injury if a seizure occurs, ensuring client safety during acute illness.

C. Sterile gloves: Standard precautions require the use of clean gloves for routine care. Sterile gloves are necessary only for invasive procedures, not for general admission care, so they are not a priority item for the room setup.

D. Tongue blade: A tongue blade is used for throat examinations but is not essential for immediate care of a client with bacterial meningitis. Priority interventions focus on monitoring neurologic status and preventing complications such as seizures.

A. The formula infusion rate of the feeding was too slow. B. The formula was given immediately following removal from the refrigerator. C. The feeding tube was partially obstructed during the infusion. D. The client is experiencing delayed gastric emptying.

Correct Answer is B

Explanation

A. The formula infusion rate of the feeding was too slow: A slow infusion rate generally decreases the risk of diarrhea because the gastrointestinal tract has more time to absorb nutrients. Rapid administration is more commonly associated with osmotic diarrhea due to overwhelming intestinal absorption capacity, so a slow rate is an unlikely cause.

B. The formula was given immediately following removal from the refrigerator: Cold formula can irritate the gastrointestinal mucosa and disrupt normal digestive enzyme activity, leading to increased motility and diarrhea. Allowing the formula to reach room or body temperature before administration helps reduce gastric upset and osmotic diarrhea.

C. The feeding tube was partially obstructed during the infusion: Partial obstruction typically slows or interrupts the flow of formula, which may cause bloating or nausea but does not usually result in diarrhea. The decreased delivery rate reduces intestinal osmotic load rather than triggering loose stools.

D. The client is experiencing delayed gastric emptying: Delayed gastric emptying slows the passage of formula into the small intestine, which can cause nausea, vomiting, or reflux, but it does not commonly cause diarrhea. Diarrhea is more associated with rapid gastric emptying or malabsorption rather than delayed emptying.

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A nurse is performing a nutritional screening for a client. Which of the following statements by the client indicates the need for further data collection?

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Correct Answer is B

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