A nurse is providing care for a client who has hypomagnesemia. Which of the following actions should the nurse take?
Check the client's deep tendon reflexes every 4 hr.
Encourage the client to consume more fiber.
Restrict the client's fluid intake to 500 mL/day.
Limit sodium-containing foods on the client's meal tray.
The Correct Answer is A
Choice A reason: Checking the client's deep tendon reflexes every 4 hr is a appropriate action for a nurse to take for a client who has hypomagnesemia. Hypomagnesemia is a low level of magnesium in the blood, which can cause neuromuscular excitability and hyperreflexia. The nurse should monitor the client's reflexes for signs of increased or decreased response, which can indicate worsening or improving hypomagnesemia.
Choice B reason: Encouraging the client to consume more fiber is not a relevant action for a nurse to take for a client who has hypomagnesemia. Fiber is beneficial for digestive health and blood glucose control, but it has no direct effect on magnesium levels. The nurse should encourage the client to consume foods that are rich in magnesium, such as green leafy vegetables, nuts, seeds, legumes, and whole grains.
Choice C reason: Restricting the client's fluid intake to 500 mL/day is not a safe or effective action for a nurse to take for a client who has hypomagnesemia. Fluid restriction can cause dehydration, electrolyte imbalance, and kidney damage, which can worsen hypomagnesemia. The nurse should maintain the client's fluid balance and monitor their urine output and specific gravity.
Choice D reason: Limiting sodium-containing foods on the client's meal tray is not a necessary action for a nurse to take for a client who has hypomagnesemia. Sodium is not directly related to magnesium levels, and limiting sodium intake can cause hyponatremia, which is a low level of sodium in the blood. The nurse should ensure that the client receives adequate sodium intake from their diet or supplements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: Nuts are not a complete protein, as they are low in the essential amino acid lysine¹. However, nuts can be combined with other plant-based foods, such as grains or legumes, to form a complete protein.
Choice B reason: Eggs are a complete protein, as they contain all nine essential amino acids in adequate amounts². Eggs are also a good source of protein, with about 6 grams per egg³.
Choice C reason: Poultry, such as chicken, turkey, or duck, is a complete protein, as it contains all nine essential amino acids in sufficient amounts⁴. Poultry is also a lean source of protein, with about 25 grams per 3-ounce serving.
Choice D reason: Legumes, such as beans, peas, or lentils, are not a complete protein, as they are low in the essential amino acid methionine. However, legumes can be combined with other plant-based foods, such as grains or nuts, to form a complete protein.
Choice E reason: Grains, such as wheat, rice, or oats, are not a complete protein, as they are low in the essential amino acid lysine. However, grains can be combined with other plant-based foods, such as legumes or nuts, to form a complete protein.
Correct Answer is D
Explanation
Choice A reason: Offering the client a selection of beverages at each meal is not a good action to include in the plan, as it may reduce the client's appetite and intake of solid foods. The nurse should limit the client's fluid intake before and during meals, and encourage the client to consume high-calorie and high-protein drinks, such as milkshakes or smoothies, after meals.
Choice B reason: Informing the client that a weight gain of 2.3 kg (5 lb) per week is expected is not a good action to include in the plan, as it may cause anxiety and resistance in the client. The nurse should set realistic and individualized weight goals for the client, and monitor the client's weight and vital signs regularly. The nurse should also avoid focusing on the client's weight, and instead emphasize the client's health and well-being.
Choice C reason: Arranging for someone to remain with the client for 30 min after meals is a good action to include in the plan, as it can prevent the client from purging or exercising excessively. The nurse should provide a supportive and nonjudgmental environment for the client, and supervise the client's eating and toileting behaviors. The nurse should also educate the client and the family about the complications and treatment of anorexia nervosa.
Choice D reason: Encouraging the client to participate in developing dietary goals is a good action to include in the plan, as it can increase the client's sense of control and motivation. The nurse should collaborate with the client, the dietitian, and the mental health team to create a personalized and flexible meal plan that meets the client's nutritional and psychological needs. The nurse should also praise the client for any progress or achievement, and reinforce the client's positive coping skills.
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