A nurse on a medical unit is observing an assistive personnel (AP) delivering food trays. Which of the following actions by the AP requires intervention?
Providing a ham and cheese sandwich to a client who follows a kosher diet
Giving peanut butter to a client who was prescribed a mechanical soft diet
Offering ginger ale to a client who is a member of the Mormon faith
Serving ice cream to a client who prescribed a full-liquid diet
The Correct Answer is A
A. Providing a ham and cheese sandwich to a client who follows a kosher diet: Kosher dietary laws prohibit pork and require specific food preparation. Giving a ham sandwich directly violates the client’s religious dietary restrictions and requires immediate correction and staff education to respect cultural and religious practices.
B. Giving peanut butter to a client who was prescribed a mechanical soft diet: A mechanical soft diet includes foods that are easy to chew and swallow. While crunchy peanut butter would be restricted, smooth peanut butter is typically allowed as it does not require significant mastication.
C. Offering ginger ale to a client who is a member of the Mormon faith: Ginger ale is nonalcoholic and caffeine-free options are usually available. Serving ginger ale is generally consistent with Mormon dietary restrictions, which prohibit alcohol and caffeinated beverages, so this does not require intervention.
D. Serving ice cream to a client who prescribed a full-liquid diet: Ice cream is considered a full-liquid food and is consistent with this diet order. It does not violate dietary guidelines, so no intervention is required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Consume a diet high in fat: Older adults are at increased risk for cardiovascular disease, hyperlipidemia, and atherosclerosis. Diets high in saturated and trans fats contribute to elevated LDL cholesterol and increased cardiovascular risk. Nutritional recommendations emphasize lean proteins, healthy fats in moderation, and balanced intake rather than high-fat consumption.
B. Drink 1 L (32 oz) water each day: Older adults typically require about 1.5 to 2 liters of fluid daily unless contraindicated by conditions such as heart failure or renal disease. A daily intake of only 1 liter may be insufficient and increases the risk of dehydration, which is more common in older adults due to decreased thirst sensation.
C. Snack between meals: Smaller, more frequent meals and snacks can help maintain caloric intake in older adults who experience decreased appetite, early satiety, or altered taste sensation. Snacking between meals supports adequate nutrient consumption and helps prevent unintended weight loss or malnutrition.
D. Eat three large meals each day: Large meals may be difficult for older adults to tolerate due to decreased gastric motility and early satiety. This pattern can lead to inadequate intake if the client cannot finish meals. Smaller, more frequent meals are generally better tolerated and promote improved nutritional status.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,C"},"C":{"answers":"A,C"},"D":{"answers":"A,B,C"},"E":{"answers":"A,C"}}
Explanation
- Muscle guarding: Muscle guarding is a classic sign of peritoneal irritation, most commonly seen in acute appendicitis. Rebound tenderness and right lower quadrant pain strongly support inflammation of the appendix. Guarding occurs as the abdominal muscles contract to protect inflamed underlying tissue. It is not typically associated with celiac disease and is less characteristic of uncomplicated diverticulitis.
- Increased temperature: Fever reflects an inflammatory or infectious process and is commonly seen in appendicitis and diverticulitis. Both conditions involve localized infection that can progress if untreated. The client’s rising temperature supports acute abdominal inflammation. Celiac disease is an autoimmune condition and does not usually present with fever.
- Nausea and vomiting: Nausea and vomiting frequently accompany appendicitis due to visceral irritation and inflammation. These symptoms can also occur in diverticulitis as a result of bowel inflammation and decreased motility. In contrast, celiac disease more commonly presents with chronic diarrhea and malabsorption rather than acute vomiting.
- Abdominal pain: Abdominal pain is present in all three conditions but differs in character and location. Appendicitis typically causes right lower quadrant pain, while diverticulitis often presents with left lower quadrant pain. Celiac disease can cause diffuse abdominal discomfort related to gluten exposure and malabsorption.
- Elevated WBC count: An elevated white blood cell count indicates an acute inflammatory or infectious process, which is characteristic of appendicitis and diverticulitis. Leukocytosis reflects the body’s immune response to bacterial infection or tissue inflammation. Celiac disease does not typically cause leukocytosis because it is a chronic autoimmune condition rather than an acute infection.
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