A nurse is planning care for a client who wants to lose weight. Which of the following actions should the nurse take first?
Set a weight loss goal.
Identify the client's motivation.
Discuss behavior modification.
Refer the client to a dietitian.
The Correct Answer is B
Choice A reason: Setting a weight loss goal is an important step in the weight management process, but it is not the first action the nurse should take. The nurse should first assess the client's readiness and willingness to change, as well as the factors that motivate the client to lose weight.
Choice B reason: Identifying the client's motivation is the first action the nurse should take, as it helps the nurse to tailor the interventions to the client's needs and preferences. The nurse should explore the client's reasons for wanting to lose weight, such as improving health, appearance, or self-esteem, and use them as positive reinforcement.
Choice C reason: Discussing behavior modification is a key component of weight management, but it is not the first action the nurse should take. The nurse should first identify the client's motivation and then help the client to develop realistic and specific goals and strategies to change their eating and physical activity habits.
Choice D reason: Referring the client to a dietitian is a helpful action, but it is not the first action the nurse should take. The nurse should first identify the client's motivation and then collaborate with the dietitian to provide individualized and evidence-based dietary advice and education to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Administering the feeding by gravity drip is not an appropriate action for a client who has a small-bore jejunostomy tube and is receiving a high-viscosity formula. Gravity drip can cause overfeeding, aspiration, and abdominal distension. The nurse should use an infusion pump to regulate the flow rate and volume of the feeding.
Choice B reason: Flushing the tubing with 10 mL water every 6 hr is an appropriate action for a client who has a small-bore jejunostomy tube and is receiving a high-viscosity formula. Flushing the tubing prevents clogging, maintains patency, and hydrates the client. The nurse should also flush the tubing before and after medication administration, and whenever the feeding is interrupted or discontinued.
Choice C reason: Replacing the bag and tubing every 24 hr is not an appropriate action for a client who has a small-bore jejunostomy tube and is receiving a high-viscosity formula. Replacing the bag and tubing every 24 hr does not prevent clogging, and may increase the risk of infection and contamination. The nurse should replace the bag and tubing every 48 hr, or as per facility policy.
Choice D reason: Heating the formula prior to infusion is not an appropriate action for a client who has a small-bore jejunostomy tube and is receiving a high-viscosity formula. Heating the formula can alter its composition, reduce its nutritional value, and increase the risk of bacterial growth. The nurse should use room-temperature formula and store it in a refrigerator when not in use.
Correct Answer is D
Explanation
Choice A reason: Drinking orange juice with iron supplements can increase absorption, not decrease it. Orange juice is rich in vitamin C, which enhances the absorption of non-heme iron, the type of iron found in plant foods and supplements. The nurse should advise the client to take iron supplements with a source of vitamin C, such as orange juice, strawberries, or tomatoes.
Choice B reason: Cooking in a stainless steel skillet does not increase the amount of iron in the food. Stainless steel is not a good conductor of iron and does not leach iron into the food. The nurse should suggest the client to use a cast iron skillet instead, which can add iron to the food, especially acidic foods like tomatoes or citrus fruits.
Choice C reason: Drinking iced tea with meals can decrease the amount of iron absorbed, not increase it. Iced tea contains tannins, which are compounds that bind to iron and inhibit its absorption. The nurse should recommend the client to avoid drinking tea, coffee, or other beverages that contain tannins with meals, and to drink them between meals instead.
Choice D reason: Fish and poultry are primary sources of heme iron, which is the type of iron found in animal foods and is more easily absorbed by the body. The nurse should encourage the client to eat more foods that are high in heme iron, such as fish, poultry, meat, and eggs.
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