Nokea
The nurse is monitoring the nutritional status of a client who is receiving enteral nutrition. Which should the nurse monitor as the best clinical indicator of the client's nutritional status?
- A. Daily weight
- B. Calorie count
- C. Skinfold measurement
- D. Serum prealbumin level
Correct Answer: D
Rationale: A serum prealbumin level is the most important parameter for determining the effectiveness of a client's nutritional management and nutritional status. Because prealbumin is a major plasma protein with a short half-life, it is sensitive to changes in protein synthesis and catabolism, and it is thus the best clinical indicator of nutritional status. It is a better nutritional index than a daily weight because body weight can be skewed quickly by changes in total body fluid. It is also a better index than anthropomorphic measurements because nutritional status is not necessarily related to skinfold thickness. The calorie count reports the total calories provided to the client without data regarding the client's use of the calories and nutrients.
You may also like to solve these questions
The nurse has created a plan of care to include interventions focused on reassuming self-care for a client who is in traction. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?
- A. The client denies a need for assistance with care.
- B. The client allows the family to assist in the care.
- C. The client assists in self-care as much as possible.
- D. The client allows the nurse to complete the care on a daily basis.
Correct Answer: C
Rationale: A successful outcome for reassuming self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refuses care or allows others to perform the care.
The nurse is reviewing the results of a client's phenytoin level that was drawn that morning. The nurse is preparing to discharge once the level is therapeutic. Which result indicates that this goal has been met?
- A. 3 mcg/mL (11.9 mcmol/L)
- B. 8 mcg/mL (31.7 mcmol/L)
- C. 15 mcg/mL (59.5 mcmol/L)
- D. 24 mcg/mL (95.2 mcmol/L)
Correct Answer: C
Rationale: The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL (39.68 to 79.36 mcmol/L) in clients with normal serum albumin levels and renal function. A level below this range indicates that the client is not receiving sufficient medication and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above the therapeutic range indicates that the client is entering the toxic range and is at risk for toxic side effects of the medication.
A client has begun medication therapy with betaxolol. The nurse determines that the client is experiencing the intended effect of therapy if which observation is noted?
- A. Edema present at 3+
- B. Weight loss of 5 pounds within 2 days
- C. Pulse rate increased from 58 to 74 beats/min
- D. Blood pressure decreased from 142 / 94mmHg to 128 / 82mmHg
Correct Answer: D
Rationale: Betaxolol is a beta-adrenergic blocking agent used to lower blood pressure, relieve angina, or eliminate dysrhythmias. Side/adverse effects include bradycardia and symptoms of heart failure, such as weight gain and increased edema.
A home care nurse is assigned to visit a preschooler who has a diagnosis of scarlet fever and is on bed rest. What data obtained by the nurse would indicate that the child is coping with the illness and bed rest?
- A. The child insists that his mother stay in the room.
- B. The child is coloring and drawing pictures in a notebook.
- C. The mother keeps providing new activities for the child to do.
- D. The child sucks his thumb whenever he does not get what he asked for.
Correct Answer: B
Rationale: According to Jean Piaget, for the preschooler, play is the best way for children to understand and adjust to life's experiences. They are able to use pencils and crayons, and they can draw stick figures and other rudimentary things. A child with scarlet fever needs quiet play, and drawing will provide that. Based on this information, none of the remaining options address positive coping mechanisms.
The nurse has provided discharge instructions to the parent of a child who has undergone heart surgery. Which statement by the parent would indicate the need for further instruction?
- A. My child can return to school for full days 2 weeks after discharge.
- B. I should allow my child to play inside but omit outside play at this time.
- C. I should have my child avoid crowds and people for 2 weeks after discharge.
- D. I should call the primary health care provider if my child develops faster or harder breathing than normal.
Correct Answer: A
Rationale: The child may return to school the third week after hospital discharge, but he or she should go to school for half days for the first week. Outside play should be omitted for several weeks, with inside play allowed as tolerated. The child should avoid crowds of people for 2 weeks after discharge, including crowds at day care centers and churches. If any difficulty with breathing occurs, the parent should notify the primary health care provider.