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A nurse is reinforcing teaching with a client who has Crohn's disease about foods to include in her diet. Which of the following foods should the nurse include in the teaching?
- A. Vanilla milkshake
- B. Buttered popcorn
- C. Broccoli
- D. Grilled chicken breast
Correct Answer: D
Rationale: Grilled chicken breast is a high-protein, low-fiber food that is well-tolerated by clients with Crohn's disease. Crohn's disease is an inflammatory bowel disease that often requires a low-fiber diet to reduce irritation to the digestive tract. Vanilla milkshake is high in dairy and sugar content, which may trigger symptoms in some individuals with Crohn's disease. Buttered popcorn and broccoli are high in fiber, which can be difficult for individuals with Crohn's disease to digest and may exacerbate symptoms.
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A nurse is collecting data from a client who has diabetes and is overweight. The client tells the nurse that she wants to start an exercise program. Which of the following actions should the nurse take first?
- A. Determine the client's usual pattern of activity.
- B. Assist the client in developing a healthy eating plan.
- C. Encourage the client to join a support group.
- D. Provide the client with a list of signs and symptoms to report to the provider.
Correct Answer: A
Rationale: Assessing the client's usual pattern of activity is crucial as it helps the nurse understand the client's current level of physical activity, any limitations, and areas needing improvement. This information is essential to create a safe and effective exercise plan tailored to the client's specific needs. Choice B, assisting the client in developing a healthy eating plan, is important but not the first step when the client's immediate goal is to start an exercise program. Encouraging the client to join a support group may be beneficial for motivation and emotional support but is not the priority at this stage. Providing a list of signs and symptoms to report to the provider is important for client education but is not the initial step when the client expresses a desire to begin an exercise program.
An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?
- A. Assess the severity and location of the pain
- B. Obtain an order for an analgesic
- C. Reassure the client that this is not unusual for his age
- D. Encourage the client to increase activity
Correct Answer: A
Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.
While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to
- A. Call the health care provider immediately
- B. Administer acetaminophen as ordered as this is normal at this time
- C. Send blood, urine, and sputum for culture
- D. Increase the client's fluid intake
Correct Answer: B
Rationale: In this scenario, the nurse should administer acetaminophen as ordered because a slight fever is normal after an MI. This intervention can help manage the fever unless other complications are present. Calling the health care provider immediately is not necessary for a slight fever post-MI. Sending blood, urine, and sputum for culture is not indicated solely based on a slight fever without other symptoms or signs of infection. Increasing fluid intake may be beneficial for various reasons but is not the priority in this situation where managing the fever with acetaminophen is appropriate.
A nurse is reinforcing teaching with a client who has a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?
- A. Eggs
- B. Grapes
- C. Pasta
- D. Dried fruits
Correct Answer: A
Rationale: The correct answer is A: Eggs. Eggs are a good protein source and are less likely to cause blockage or odor issues in clients with colostomies. Grapes, pasta, and dried fruits can be problematic for individuals with colostomies as they may cause digestive issues, blockages, or increased gas production. Grapes have skins that are hard to digest, pasta can cause constipation or blockage, and dried fruits are high in fiber which can lead to blockages.
A client who is 2 days postoperative following abdominal surgery is transitioning from a clear liquid diet to a full liquid diet. The nurse should remind the client that which of the following items is included in a full liquid diet?
- A. Creamed peas
- B. Cottage cheese
- C. Chocolate pudding
- D. Applesauce
Correct Answer: C
Rationale: The correct answer is C, chocolate pudding. A full liquid diet consists of smooth, creamy foods like pudding. Creamed peas (choice A) are not typically allowed on a full liquid diet as they may contain solid pieces. Cottage cheese (choice B) and applesauce (choice D) are also not part of a full liquid diet as they are not in liquid form.