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The nurse is admitting a client diagnosed with protein calorie malnutrition. Which interventions should the nurse implement? Select all that apply.
- A. Place the client on a 72-hour calorie count.
- B. Ask the client to describe the stools.
- C. Have the UAP weigh the client.
- D. Obtain a list of current medications.
- E. Make a referral to the dietitian.
Correct Answer: A,C,D,E
Rationale: Calorie count, weight, medication list, and dietitian referral assess and manage malnutrition. Stool description is less relevant unless GI issues are present.
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Which diagnostic test should the nurse monitor for the client diagnosed with severe anorexia nervosa?
- A. Liver function tests.
- B. Kidney function tests.
- C. Cardiac function tests.
- D. Bone density scan.
Correct Answer: C
Rationale: Cardiac function tests (e.g., ECG) monitor for arrhythmias or heart failure, common in severe anorexia due to electrolyte imbalances and starvation. Liver, kidney, and bone tests are less urgent.
The client receiving antibiotic therapy complains of white, cheesy plaques in the mouth. Which intervention should the nurse implement?
- A. Notify the health-care provider to obtain an antifungal medication.
- B. Explain the patches will go away naturally in about two (2) weeks.
- C. Instruct to rinse the mouth with diluted hydrogen peroxide and water daily.
- D. Allow the client to verbalize feelings about having the plaques.
Correct Answer: A
Rationale: White, cheesy plaques suggest oral candidiasis, a common side effect of antibiotics. Notifying the HCP for an antifungal medication is the most appropriate intervention. The patches won’t resolve naturally, hydrogen peroxide is not standard, and verbalizing feelings is secondary.
The client is diagnosed with esophageal diverticula. Which lifestyle modification should be taught by the nurse?
- A. Raise the foot of the bed to 45 degrees to increase peristalsis.
- B. Eat the evening meal at least two (2) hours prior to bed.
- C. Eat a low-fat, low-cholesterol, high-fiber diet.
- D. Wear an abdominal binder to strengthen the abdominal muscles.
Correct Answer: B
Rationale: Eating at least two hours before bed prevents food pooling in the diverticula, reducing regurgitation risk. Raising the bed foot, specific diets, and binders are not standard.
The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first?
- A. Check for a fecal impaction.
- B. Encourage the client to drink fluids.
- C. Check the chart for sodium and potassium levels.
- D. Apply a protective barrier cream to the perianal area.
Correct Answer: D
Rationale: Dark, watery stool risks perianal skin breakdown, so applying a barrier cream is the first intervention. Impaction is unlikely, fluids are secondary, and labs follow assessment.
The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer?
- A. Beginning at age 60, a digital rectal examination should be done yearly.
- B. After reaching middle age, a yearly fecal occult blood test should be done.
- C. Have a colonoscopy at age 50 and then once every five (5) to 10 years.
- D. A flexible sigmoidoscopy should be done yearly after age 40.
Correct Answer: C
Rationale: The American Cancer Society recommends a colonoscopy starting at age 45–50, then every 5–10 years for average-risk individuals, as it effectively detects polyps and cancer. Other options are outdated or incorrect.