A nurse is providing teaching about dietary recommendations to a client who has iron deficiency anemia. Which of the following dietary recommendations should the nurse include as a food that enhances iron absorption when consumed with nonheme iron?

Tea

Dried beans

Milk

Tomato juice

Answer and Explanation

The Correct Answer is D

Choice A reason: Tea

Tea contains polyphenols and tannins, which can inhibit the absorption of nonheme iron. Therefore, it is not recommended to consume tea with iron-rich foods if the goal is to enhance iron absorption.

Choice B reason: Dried beans

Dried beans are a good source of nonheme iron, but they do not enhance its absorption. In fact, beans contain phytates, which can inhibit iron absorption. While they are beneficial for iron intake, they should be consumed with foods that enhance iron absorption, such as those rich in vitamin C.

Choice C reason: Milk

Milk contains calcium, which can inhibit the absorption of both heme and nonheme iron. Therefore, it is not recommended to consume milk with iron-rich foods if the goal is to enhance iron absorption.

Choice D reason: Tomato juice

Tomato juice is rich in vitamin C, which significantly enhances the absorption of nonheme iron. Consuming vitamin C-rich foods like tomato juice with iron-rich foods can improve the body’s ability to absorb iron, making it an excellent choice for individuals with iron deficiency anemia.

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Correct Answer is A

Explanation

Choice A reason:

The statement “Muffled heart sounds” is a classic sign of cardiac tamponade. This condition occurs when fluid accumulates in the pericardium (the sac around the heart), compressing the heart and preventing it from functioning properly. Muffled heart sounds are due to the fluid dampening the sound of the heartbeats. This is part of Beck’s triad, which also includes hypotension and jugular venous distension.

Choice B reason:

The statement “Sudden lethargy” is not a specific indicator of cardiac tamponade. While lethargy can occur due to decreased cardiac output and poor perfusion, it is not a definitive sign of cardiac tamponade. Lethargy can be caused by various conditions and is not specific enough to support the suspicion of cardiac tamponade.

Choice C reason:

The statement “Flattened neck veins” is incorrect. In cardiac tamponade, one would expect to see distended (bulging) neck veins due to increased central venous pressure. Flattened neck veins are not consistent with the hemodynamic changes seen in cardiac tamponade.

Choice D reason:

The statement “Bradycardia” is not typically associated with cardiac tamponade. Instead, tachycardia (an increased heart rate) is more commonly seen as the body attempts to compensate for decreased cardiac output. Bradycardia can occur in severe cases or as a pre-terminal event, but it is not a primary indicator of cardiac tamponade.

A. Apply a heat lamp twice a day. B. Reposition the client at least every 2 hours. C. Massage reddened areas with dressing changes. D. Clean the wound with hydrogen peroxide solution.

Correct Answer is B

Explanation

Choice A reason:

Applying a heat lamp twice a day is not recommended for treating stage 3 pressure ulcers. Heat lamps can cause burns and further damage to the already compromised skin. The primary goal in treating pressure ulcers is to reduce pressure, keep the area clean, and promote healing. Heat lamps do not contribute to these goals and can potentially worsen the condition.

Choice B reason:

Repositioning the client at least every 2 hours is a crucial intervention for managing stage 3 pressure ulcers. Frequent repositioning helps to alleviate pressure on the affected area, improving blood flow and preventing further tissue damage. This practice is essential in preventing the progression of pressure ulcers and promoting healing. It is one of the most effective strategies in pressure ulcer management.

Choice C reason:

Massaging reddened areas with dressing changes is not advisable. Massaging can cause additional trauma to the skin and underlying tissues, potentially worsening the ulcer. Instead, gentle handling and appropriate wound care techniques should be used to avoid further damage. Massaging can also disrupt the healing process and increase the risk of infection.

Choice D reason:

Cleaning the wound with hydrogen peroxide solution is not recommended for stage 3 pressure ulcers. Hydrogen peroxide can damage healthy tissue and delay the healing process. It is better to use saline or other wound cleaning solutions that are gentle and effective in removing debris without harming the tissue. Proper wound cleaning is essential to prevent infection and promote healing.

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A nurse is providing teaching about dietary recommendations to a client who has iron deficiency anemia. Which of the following dietary recommendations should the nurse include as a food that enhances iron absorption when consumed with nonheme iron?

Nursing Test Bank

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