A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?

Puffed rice cereal

Tomato juice

Bran muffin

Cottage cheese

None

Answer and Explanation

The Correct Answer is C

Choice A reason: Puffed rice cereal lacks significant fiber, offering minimal bulk to stimulate peristalsis. It’s a poor choice for constipation relief, as it doesn’t soften stool or aid movement.

Choice B reason: Tomato juice provides hydration and some nutrients, but its low fiber content doesn’t effectively combat constipation. High-fiber foods are needed to increase stool bulk instead.

Choice C reason: Bran muffins are high in insoluble fiber, adding bulk and water to stool, promoting bowel movements. This choice reflects understanding of constipation management through diet.

Choice D reason: Cottage cheese is low in fiber, offering protein but no relief for constipation. It doesn’t enhance intestinal motility or stool consistency, making it an ineffective option.

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Correct Answer is D

Explanation

Choice A reason: Exchange transfusion treats severe conditions like hyperbilirubinemia, not HIV. It’s irrelevant for a 10-month-old’s ongoing viral management needs.

Choice B reason: Granulocyte colony-stimulating factor boosts neutrophils, not lymphocytes, in neutropenia. HIV targets CD4 cells, making this an ineffective intervention here.

Choice C reason: Droplet precautions suit respiratory infections, not HIV, which spreads via blood/body fluids. Standard precautions suffice, so this isn’t needed.

Choice D reason: Monitoring lymphocyte (CD4) count tracks HIV progression in infants. It guides antiretroviral therapy, a critical ongoing management step at 10 months.

A. Release the client’s restraints every 4 hr. B. Check the client’s status every hour. C. Obtain written consent by the client for the placement of the restraints. D. Document the client’s behavior leading to the initiation of the restraints.

Correct Answer is D

Explanation

Choice A reason: Releasing restraints every 4 hours lacks context; policy requires 2-hour checks with release if safe. Scientifically, this risks neglect, as frequent assessment ensures circulation and safety, making it less precise than behavior documentation.

Choice B reason: Hourly checks are good but not the action specified; 15-minute intervals are standard for restraints. Scientifically, this underestimates risk monitoring needs, as behavior justification is a legal and clinical priority over timing alone.

Choice C reason: Client consent isn’t required for restraints in emergencies; provider orders suffice. Scientifically, imminent harm overrides autonomy, and consent isn’t feasible mid-crisis, making this impractical and misaligned with restraint protocols.

Choice D reason: Documenting behavior justifies restraints, ensuring legal and ethical use for safety. Scientifically, this aligns with standards, as specific actions (e.g., aggression) validate intervention, providing a clinical basis critical for care continuity and review.

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A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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