The nurse is providing education to a client about nutrition. Which foods should the client be instructed to limit in their diet? (Select all that apply)

Choice A Reason:

The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.

Choice B Reason:

The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.

Choice C Reason:

The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.

Choice D Reason:

The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.

Choice A reason: Apple juice is an appropriate choice for a full liquid diet. It is a clear liquid that provides hydration and some nutrients without putting strain on the digestive system. Apple juice is easily digestible and does not contain any solid particles that could be problematic for a client recovering from abdominal surgery.

Choice B reason: Smoothies can be included in a full liquid diet as long as they are well-blended and do not contain any solid chunks. Smoothies can provide essential nutrients and calories, which are important for recovery. They can be made with fruits, vegetables, and protein supplements to ensure a balanced intake.

Choice C reason: Mashed potatoes and gravy are not suitable for a full liquid diet. Although mashed potatoes are soft, they are not liquid and can be difficult to digest for someone on a full liquid diet. The gravy may also contain small particles or thickeners that are not appropriate for this diet. A full liquid diet is intended to include only foods that are completely liquid or will turn to liquid at room temperature.

Choice D reason: Chicken broth is an excellent choice for a full liquid diet. It is a clear liquid that provides hydration and some nutrients without adding any solid particles to the diet. Chicken broth is gentle on the digestive system and can help maintain electrolyte balance.