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The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing is not an issue?
- A. Cheeseburger and milk shake.
- B. Canned peaches and a sandwich on whole-wheat bread.
- C. Mashed potatoes and mechanically ground red meat.
- D. Biscuits and gravy with bacon.
Correct Answer: C
Rationale: Mashed potatoes and ground meat are soft, low-fiber, and digestible, suitable for immobile clients to prevent constipation. Burgers, whole-wheat, and fatty foods are harder to digest.
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The nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis?
- A. The client reports up to 20 bloody stools per day.
- B. The client has a feeling of fullness after a heavy meal.
- C. The client has diarrhea alternating with constipation.
- D. The client complains of right lower quadrant pain.
Correct Answer: C
Rationale: Alternating diarrhea and constipation are common in rectosigmoid colon cancer due to partial obstruction by the tumor. Frequent bloody stools are more typical of ulcerative colitis, fullness is nonspecific, and right lower quadrant pain is less likely with rectosigmoid involvement.
The client is diagnosed with peritonitis. Which assessment data indicate to the nurse the client's condition is improving?
- A. The client is using more pain medication on a daily basis.
- B. The client's nasogastric tube is draining coffee-ground material.
- C. The client has a decrease in temperature and a soft abdomen.
- D. The client has had two (2) soft-formed bowel movements.
Correct Answer: C
Rationale: A decrease in temperature and a soft abdomen indicate resolving infection and inflammation in peritonitis. Increased pain medication, coffee-ground drainage, and bowel movements are not improvement signs.
Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning?
- A. Fluid volume deficit.
- B. Nausea.
- C. Risk for aspiration.
- D. Impaired urinary elimination.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in elderly patients with gastroenteritis, as dehydration from vomiting and diarrhea poses significant risks. Nausea, aspiration, and urinary issues are secondary.
The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next?
- A. Call the HCP and suggest he or she talk with the client.
- B. Determine what about the HCP is bothering the client.
- C. Notify the nursing supervisor to arrange a new HCP to take over.
- D. Explain the client cannot request another HCP until after discharge.
Correct Answer: B
Rationale: Determining the specific issue allows the nurse to address the concern effectively, whether through communication, advocacy, or escalation. Contacting the HCP or supervisor prematurely or dismissing the client’s request is less appropriate.
The home health nurse is performing a follow-up visit for the client diagnosed with chronic hepatitis B. The client is being treated with interferon alpha-2b. Which client comment requires further assessment by the nurse?
- A. “My clothes are tight; I gained 2 pounds this month.”
- B. “Whenever I just bump into anything, I get a bruise.”
- C. “I’ve been staying home and avoiding large crowds.”
- D. “I get tired easily, so I just take my time with things.”
Correct Answer: B
Rationale: A. Anorexia is commonly seen with hepatitis B. A weight gain of 2 lb in one month would typically not be a cause for concern. B. Bruising can indicate thrombocytopenia, which is an adverse effect of treatment. Thrombocytopenia can also occur from liver dysfunction. C. Avoiding large crowds is appropriate; the client will be at increased risk for infection while taking interferon alpha-2b. D. Fatigue is commonly associated with chronic hepatitis B.