The nurse is assessing a client who has been experiencing prolonged stress. For which most serious complication should the nurse monitor the client?

Increased muscle tension

Altered sleep patterns

Increased peristalsis

Impaired immunity

Answer and Explanation

The Correct Answer is D

D. Impaired immunity is a serious complication of prolonged stress that can have significant implications for overall health and susceptibility to illness. Chronic stress has been linked to dysregulation of the immune system, leading to decreased immune function and increased susceptibility to infections, autoimmune disorders, and other illnesses. Impaired immunity can compromise the body's ability to fight off pathogens and may contribute to the development or exacerbation of various health conditions.
A. Increased muscle tension is a common physiological response to stress but it is not typically considered a serious complication. Prolonged muscle tension can lead to discomfort, headaches, and musculoskeletal issues, but it is not usually life-threatening or associated with severe complications.
B. Altered sleep patterns, such as insomnia or disrupted sleep, can be significant consequences of prolonged stress. Chronic sleep disturbances can negatively impact physical health, cognitive function, and emotional well-being. While altered sleep patterns can have serious implications for overall health and quality of life, they are not typically considered life-threatening in the short term.
C. Increased peristalsis refers to heightened movement of the gastrointestinal tract, which can result in symptoms such as diarrhea or gastrointestinal discomfort. While gastrointestinal disturbances are common manifestations of stress, they are generally not considered the most serious complication of prolonged stress. However, severe or persistent gastrointestinal symptoms may warrant medical evaluation and management.

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Correct Answer is ["B","D"]

Explanation

B. Liquid medications are generally preferred for administration through a feeding tube, as they do not require crushing or dissolving and can be easily administered. Using liquid medications reduces the risk of tube occlusion and ensures accurate dosing. Therefore, this procedure is appropriate for medications available in liquid form.

D. Flushing the tube before medication administration helps ensure patency and clears any residual feeding formula or medication from the tube. This step is essential to prevent clogging of the tube and ensure that the medication reaches the stomach or intestines. Therefore, flushing the tube with water or saline before medication administration is a standard procedure.
A. Crushing tablets and mixing them with water or saline can help ensure that the medication is in a form that can be administered through the gastrostomy tube. However, not all tablets are suitable for crushing, as some medications may have special formulations or coatings that should not be crushed.
Therefore, this procedure is appropriate for medications that are safe to crush and administer via a feeding tube.
C. Mixing medications can potentially alter their effectiveness or stability, so it is essential to follow guidelines and recommendations for medication administration through feeding tubes.
E. Adding medications directly to the tube feeding formula may be appropriate for certain medications that are compatible with the formula and do not require separate administration. However, not all medications can be safely mixed with feeding formula, as some medications may interact with the formula components or become less effective.

A. "Enteral nutrition may be used in addition to or instead of oral intake." B. "Most enteral nutrition consists of thinned pureed food." C. "Enteral nutrition can be given either intermittently or continuously." D. "Enteral nutrition is milk based." E. "Enteral nutrition can be given through a vein."

Correct Answer is ["A","C"]

Explanation

A. Enteral nutrition can be used when a client is unable to consume adequate nutrition orally or when oral intake is contraindicated. It can be used as a supplement to oral intake or as the sole source of nutrition, depending on the client's condition and nutritional needs.
C. Enteral nutrition can be administered either intermittently, where feedings are given at specific times throughout the day, or continuously, where a steady infusion is delivered over an extended period, typically 16 to 24 hours. The method of administration depends on the client's tolerance, nutritional needs, and clinical condition.
B. Enteral nutrition typically consists of liquid formulas specifically designed to provide complete and balanced nutrition. These formulas come in various formulations, including standard polymeric formulas, high-protein formulas, elemental formulas, and disease-specific formulas. They are not thinned pureed food, which is typically used for clients with dysphagia or swallowing difficulties who are receiving oral feeding.
D. While some enteral nutrition formulas may contain dairy-based ingredients, such as milk protein or lactose, not all enteral formulas are milk-based. There are various types of enteral formulas available, including those that are lactose-free, soy-based, or elemental (containing predigested nutrients), to accommodate different dietary preferences and tolerances.
E. Enteral nutrition is administered directly into the gastrointestinal tract, typically through a feeding tube that is inserted into the stomach or small intestine. It is not given intravenously (through a vein), which would be parenteral nutrition.

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The nurse is assessing a client who has been experiencing prolonged stress. For which most serious complication should the nurse monitor the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering medications to a client receiving tube feedings through a gastrostomy tube. The correct procedure for administration is to: (SELECT ALL THAT APPLY)

Correct Answer is ["B","D"]

Explanation

A client is to receive enteral nutrition. Which information should the nurse provide to the client and family? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C"]

Explanation

A client is receiving an intravenous (IV) solution over a short amount of time to replace volume losses. The nurse understands that this IV solution is most likely to be:

The client experiencing abdominal distention and severe vomiting has just had a nasogastric (NG) tube inserted. When teaching this client, which rationale for the use of the NG tube should the nurse include?

The nurse recognizes that the appropriate rationale for using an IV infusion pump for a client is to:

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