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The weight loss clinic nurse identifies the concept of nutrition for a client diagnosed with obesity. Which interventions should the nurse implement? Select all that apply.
- A. Ask the client about previous diet attempts.
- B. Refer the client to the dietitian.
- C. Discuss maintaining a sedentary lifestyle.
- D. Weigh the client.
- E. Assist the client to set a realistic weight loss goal.
Correct Answer: A,B,D,E
Rationale: Asking about diets, dietitian referral, weighing, and setting goals support nutritional management for obesity. A sedentary lifestyle is contraindicated.
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The nurse has received the a.m. shift report. Which client should the nurse assess first?
- A. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain.
- B. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night.
- C. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes.
- D. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.
Correct Answer: C
Rationale: Tented skin turgor and dry mucous membranes in an elderly IBD patient indicate severe dehydration, a life-threatening condition requiring immediate assessment. Other clients have concerning but less urgent symptoms.
The nurse caring for a client diagnosed with GERD writes the client problem of 'behavior modification.' Which intervention should be included for this problem?
- A. Teach the client to sleep with a foam wedge under the head.
- B. Encourage the client to decrease the amount of smoking.
- C. Instruct the client to take over-the-counter medication for relief of pain.
- D. Discuss the need to attend Alcoholics Anonymous to quit drinking.
Correct Answer: A
Rationale: Sleeping with a foam wedge elevates the head, reducing reflux by preventing stomach acid from flowing into the esophagus during sleep, a key behavioral modification for GERD. Smoking cessation is beneficial but less specific to immediate symptom relief, and the other options are not directly related to behavior modification for GERD.
The client has diarrhea that has been cultured positive for Clostridium difficile (C. diff). In order to prevent the spread of infection, the nurse should perform which intervention?
- A. Wear an isolation gown, gloves, and mask when providing care.
- B. Perform vigorous hand hygiene using only soap and water.
- C. Place the client in a private room with negative pressure airflow.
- D. Instruct visitors to use the alcohol-based hand wash for self-protection.
Correct Answer: B
Rationale: A. The nurse does not need to wear a mask when caring for the client; the bacterium is transmitted through direct contact. B. Hand washing with soap and water is performed instead of using alcohol—based hand cleaners; alcohol-based cleaners lack sporicidal activity. Even vigorous scrubbing with soap and water does not kill all of the spores. C. The client should be in a private room but does not need a negative pressure room. Negative pressure rooms are used with airborne diseases. D. The spores of C. diff can survive on inanimate objects such as tables and bedrails. For self-protection, visitors should be instructed to wash vigorously with soap and water and not to use the alcohol-based hand wash.
Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism?
- A. Make sure all hamburger meat is well cooked.
- B. Ensure all dairy products are refrigerated.
- C. Discuss why campers should drink only bottled water.
- D. Discard damaged canned goods.
Correct Answer: D
Rationale: Clostridium botulinum thrives in improperly canned foods, so discarding damaged cans prevents botulism. Cooking meat, refrigerating dairy, and bottled water are unrelated to botulism.
The nurse is assessing the client who is 24 hours post—GI hemorrhage. The findings include BUN of 40 mg/dL and serum creatinine of 0.8 mg/dL. Which action should be taken by the nurse?
- A. Immediately call the health care provider to report these results.
- B. Monitor urine output, as this may be a sign of kidney failure.
- C. Document the findings and continue to monitor the client.
- D. Encourage the client to limit his or her dietary protein intake.
Correct Answer: C
Rationale: A. No treatment is required; it is unnecessary to call the HCP. B. If acute kidney failure is present, both the BUN and creatinine would be elevated. C. The findings should be documented. The BUN can be elevated after a significant GI hemorrhage from the breakdown of blood proteins. The protein breakdown releases nitrogen that is then converted to urea. D. Limiting protein intake in the presence of healthy kidneys is unnecessary.