During a home visit, a nurse is assessing the nutritional awareness of an older adult patient who lives alone. The nurse is most effective in obtaining objective information when:
observing the patient eat a meal that he or she has prepared
reviewing the components of a healthy diet with the patient
asking to see what types of foods the patient keeps readily available
asking the patient to describe what he or she ate for all three meals yesterday
The Correct Answer is A
A. Observing the patient eat a meal that he or she has prepared provides the nurse with direct, objective information about the patient's nutritional intake. This can help the nurse assess the patient's food choices, portion sizes, and overall dietary habits.
B. While this can be helpful in educating the patient about nutrition, it does not provide direct information about the patient's actual dietary habits.
C. This can provide some insight into the patient's dietary habits, but it may not be a complete picture, as the patient may not eat everything they have on hand.
D. This can provide some information about the patient's dietary intake, but it may be difficult for the patient to recall everything they ate, especially if their memory is impaired.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Observing the patient eat a meal that he or she has prepared provides the nurse with direct, objective information about the patient's nutritional intake. This can help the nurse assess the patient's food choices, portion sizes, and overall dietary habits.
B. While this can be helpful in educating the patient about nutrition, it does not provide direct information about the patient's actual dietary habits.
C. This can provide some insight into the patient's dietary habits, but it may not be a complete picture, as the patient may not eat everything they have on hand.
D. This can provide some information about the patient's dietary intake, but it may be difficult for the patient to recall everything they ate, especially if their memory is impaired.
Correct Answer is D
Explanation
A. Reflex tone refers to the neurological response of the body to stimuli and is not directly related to the action or monitoring of anticoagulant therapy. While assessing reflexes might be important for overall patient health, it is not specifically relevant to monitoring the effects of warfarin. Reflex tone does not provide information on the anticoagulation status or risk of bleeding associated with warfarin therapy.
B. Checking the body for bruising helps assess the safety of warfarin therapy and may indicate the need for dosage adjustments or further investigation if bruising is excessive. However, while monitoring for bruising is essential, it is not the primary method for assessing the effectiveness and safety of anticoagulant therapy.
C. While monitoring kidney function is relevant for overall medication management, it is not the primary focus for directly assessing the effectiveness or safety of warfarin therapy. Kidney function is more related to adjusting doses and avoiding potential complications.
D. Regularly reviewing PT is crucial for managing warfarin therapy because it directly reflects the anticoagulation effect of the medication. The International Normalized Ratio (INR), derived from PT, is used to ensure the patient is within the therapeutic range for effective anticoagulation while minimizing the risk of bleeding.
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