Nokea
A nurse is caring for a client who has a body mass index (BMI) of 30. Four weeks after nutritional counseling, which of the following evaluation findings indicates the plan of care was followed?
- A. BMI of 25
- B. Weight gain of 1.8 kg
- C. BMI of 33
- D. Weight loss of 2.7 kg
Correct Answer: D
Rationale: A weight loss of 2.7 kg in four weeks indicates effective adherence to a nutritional plan aimed at reducing body mass index (BMI), moving towards a healthier weight. Choices A, B, and C are incorrect because a decrease in weight, as shown in choice D, is the desired outcome when managing a client with a BMI of 30 to reach a healthier range.
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A nurse is teaching a group of clients about stress. Which of the following should the nurse include in the teaching?
- A. Protein requirements decrease in times of stress.
- B. Acute stress causes an increase in metabolism.
- C. Stress causes a positive nitrogen balance in the body.
- D. Glucose is broken down more slowly during times of stress.
Correct Answer: B
Rationale: The correct answer is B: Acute stress causes an increase in metabolism. During acute stress, the body's fight-or-flight response is activated, leading to an increase in metabolism to provide energy for the body to respond to the stressor. Choices A, C, and D are incorrect. Protein requirements actually increase during times of stress to support the body's needs. Stress typically leads to a negative nitrogen balance in the body, not a positive one. Glucose is broken down more rapidly, not slowly, during times of stress to provide immediate energy.
A client is receiving education from a nurse regarding the dietary changes needed for weight loss. Which of the following actions should the nurse perform first?
- A. Educate the client about daily caloric requirements.
- B. Determine the client's daily caloric intake.
- C. Provide the client with meal planning information.
- D. Show the client how to identify the fat content of packaged foods.
Correct Answer: B
Rationale: The correct answer is to determine the client's daily caloric intake first. This step is crucial in understanding the client's current dietary habits and establishing a baseline for creating an effective weight loss plan. Educating the client about daily caloric requirements (Choice A) can only be done effectively after knowing the client's current intake. Providing meal planning information (Choice C) and teaching the client how to identify fat content in foods (Choice D) come after determining the baseline caloric intake to tailor the plan accordingly.
A client who practices Islam and is currently observing dietary restrictions for the month of Ramadan. Which of the following interventions should the nurse include in the plan of care?
- A. Remove pork products from the dietary plan
- B. Facilitate fasting during daylight hours
- C. Serve meat and dairy items together
- D. Provide a low-carb diet on Fridays
Correct Answer: B
Rationale: During Ramadan, individuals fast from dawn to sunset. Facilitating fasting during daylight hours respects the dietary practices of clients observing Ramadan. Choice A is incorrect as the dietary restriction during Ramadan involves abstaining from all food and drink during daylight hours, not just beef products. Choice C is incorrect as Muslims generally do not consume meat and dairy together due to religious dietary laws. Choice D is incorrect as providing a low-carb diet on Fridays does not specifically align with the dietary restrictions observed during Ramadan.
A nurse is reviewing the medication administration record for a client who is 2 days postoperative following abdominal surgery. The nurse should recognize that which of the following medications places the client at risk for wound dehiscence?
- A. Omeprazole
- B. Zolmitriptan
- C. Prednisone
- D. Verapamil
Correct Answer: C
Rationale: Corrected Rationale: Prednisone is a corticosteroid that can impair wound healing and increase the risk of wound dehiscence. Omeprazole (Choice A) is a proton pump inhibitor used to reduce stomach acid production and does not directly impact wound healing. Zolmitriptan (Choice B) is a medication used to treat migraines and does not affect wound healing. Verapamil (Choice D) is a calcium channel blocker used to treat high blood pressure and certain heart conditions, and it does not pose a significant risk for wound dehiscence.
A nurse is developing a plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to participate in developing a system of rewards.
- B. Arrange for someone to remain with the client for 30 minutes after meals.
- C. Offer the client a selection of beverages at each meal.
- D. Inform the client that a weight gain of 2.3 kg per week is expected.
Correct Answer: A
Rationale: Encouraging the client to participate in developing a system of rewards is an essential part of the plan of care for a client with anorexia nervosa. This action can help motivate and engage the client in their treatment plan, promoting a sense of achievement and progress. Choice B, arranging for someone to remain with the client for 30 minutes after meals, may not address the underlying issues related to anorexia nervosa and could potentially disrupt the client's independence. Choice C, offering a selection of beverages at each meal, is not directly related to addressing the client's condition of anorexia nervosa. Choice D, informing the client about an expected weight gain, could increase anxiety and may not be appropriate without considering the client's individual progress and readiness.