EXPLANATION

Correct: A BMI of 17(a) is low, and a BMI of 30 shows obesity. Both of these individuals should have a further assessment of their nutritional status.
Incorrect: A BMI of 21 is normal, and a BMI of 25 is 0.1 above average.

LEARNING OBJECTIVE
While a detailed nutritional assessment is not part of a history and physical, BMI is determined from height and weight, eluding to the need for further investigation. Other information collected in the history may also indicate that a nutritional assessment is required. While collecting the information, nurses must process and consider recommendations such as nutritional assessments based on their findings.

For correct answer choice:

Inspection is correct. The first step in the abdominal assessment is always inspection in which the nurse visually examines the abdomen for distention, symmetry, skin abnormalities, and any visible pulsations or movements. This provides crucial information about the patient’s condition before proceeding to a hands-on examination.

For incorrect answer choices:

Auscultation is incorrect. This should occur after inspection. The nurse would auscultate to listen for bowel sounds, which is important to determine gastrointestinal function. Auscultation is performed before palpation or percussion to avoid altering the natural state of the abdomen.

Percussion is incorrect. This is used to assess the density of abdominal contents and may help identify fluid or masses, but it is performed after auscultation.

Palpation is incorrect. Palpation is a physical examination technique used to assess tenderness, organ enlargement, or masses. It is performed last to minimize discomfort and avoid disrupting bowel sounds.

For correct answer choice:

Try consuming nutrient-dense snacks like smoothies or protein shakes is correct. Nutrient-dense snacks, such as smoothies and protein shakes, are ideal for patients with low appetite because they provide a concentrated source of calories and nutrients in a form that is often easier to consume. These snacks can also be more palatable and less overwhelming than large meals.

For incorrect answer choices:

Wait until feeling hungry to eat to avoid nausea is incorrect. Waiting for hunger signals may result in long periods without eating, exacerbating weight loss and nutritional deficiencies. Even if the patient doesn’t feel particularly hungry, encouraging small, frequent meals is better.

Eat large meals with a variety of food groups at mealtimes is incorrect. Large meals may be too difficult to tolerate for patients experiencing nausea and appetite loss due to chemotherapy. Small, frequent meals or nutrient-dense snacks are more effective in managing these symptoms.

Focus on eating salty or spicy foods to stimulate appetite is incorrect. While some patients may prefer stronger flavors, spicy or salty foods can irritate the digestive tract and worsen nausea for some patients undergoing chemotherapy. It's best to suggest bland, easy-to-digest foods or snacks that the patient finds tolerable.

For correct answer choice:

Elevate the head of the bed to at least 45 degrees is correct. This is an important action to reduce the risk of aspiration, particularly in patients with GERD. Elevating the head of the bed helps prevent stomach contents from refluxing into the esophagus and potentially entering the lungs, which is crucial for patient safety during enteral feedings.

For incorrect answer choices:

Verify tube placement using radiography is incorrect. While radiographic confirmation is critical at the initial placement of the nasogastric tube, for routine feedings, verification through other methods (such as pH testing or aspiration) is typically sufficient unless complications are suspected.

Measure the patient’s abdominal girth is incorrect. Measuring abdominal girth can help assess for distension or other gastrointestinal issues but is not the priority before feeding. Reducing the risk of aspiration takes precedence over this assessment.

Administer antiemetic medication prophylactically is incorrect. Administering antiemetics is not routinely necessary before every feeding unless the patient has a known history of nausea or vomiting with enteral nutrition. The priority should be proper positioning to minimize aspiration risk.

For correct answer choice:

Caregiver Role Strain related to high levels of caregiver stress is correct. The wife’s report of feeling overwhelmed and exhausted indicates significant caregiver role strain. Addressing the emotional and physical burden on the caregiver is critical, as it affects both the caregiver's well-being and the quality of care provided to the patient.

For incorrect answer choices:

Risk for Injury related to patient confusion and wandering is incorrect. While the patient's confusion and wandering do indeed pose a risk for injury, the more immediate concern expressed by the wife is her exhaustion and stress. Therefore, addressing caregiver role strain takes precedence in this scenario.

Ineffective Family Coping related to Alzheimer’s progression is incorrect. Although coping difficulties may be present, the primary issue reported here is the wife’s stress and exhaustion from caregiving responsibilities, which points more directly to caregiver role strain rather than general ineffective family coping.

Impaired Memory related to cognitive decline from Alzheimer’s disease is incorrect. Impaired memory is a symptom of Alzheimer’s disease, but in this case, the nursing diagnosis should focus on the broader impact of caregiving stress rather than solely on the patient's cognitive decline.

EXPLANATION
Correct: Wash hands with soap and water. The first step is to wash your hands with soap and water before preparing your supplies(a).

Incorrect: After completing the above steps, you explain the procedure to the patient. Next, you fill the catheter-size tip syringe with saline. Before donning a fresh pair of gloves, wash your hands with soap and water and complete the rest of the procedure, including flushing with saline solution(c).

LEARNING OBJECTIVE
Nurses must accurately assess their patients and be prepared to perform procedures. Always remember handwashing is the first step in the prevention of infection. Quick actions prevent complications when proper procedures are followed.

For correct answer choice:

"You might feel a little pinch, like when you get a shot." is correct. This statement is appropriate because it uses familiar language that a young child can understand. Comparing the sensation to something the child might already know, for example, a shot, helps set realistic expectations and minimizes fear by normalizing the experience.

For incorrect answer choices:

"Try not to cry. It’s just a quick poke." is incorrect. This statement can be dismissive of the child’s feelings and may increase anxiety by implying that crying is bad behavior. Acknowledging the child's emotions and providing support rather than discouraging natural responses is important.

"I’m going to put a bandage on your arm after this." is incorrect. While this statement may be part of the overall explanation, it does not directly address the child’s anxiety about the procedure itself. It’s better to focus on the child's feelings during the procedure.

"You have to be good and hold still, or this will hurt a lot." is incorrect. This statement can be perceived as a threat and may increase the child’s anxiety and fear. It’s not appropriate to use language that suggests punishment or additional pain based on the child’s behavior.

For correct answer choice:

Milk is correct. Milk is not allowed on a clear liquid diet because it contains fat and protein, which require digestion. Consumption of milk can stimulate gastric activity, which is undesirable for patients recovering from surgery or preparing for certain medical procedures.

For incorrect answer choices:

Chicken broth is incorrect. This is an appropriate choice for a clear liquid diet. It provides hydration and electrolytes while being easy to digest and free of solid particles.

Black coffee is incorrect. Black coffee is acceptable on a clear liquid diet as long as it contains no milk or cream.

Clear apple juice is incorrect. Apple juice is considered a clear liquid since it is transparent and free of solid particles. It is suitable for a clear liquid diet that aids hydration without taxing the digestive system.

EXPLANATION
Correct: All of the above: Risk for impaired glucose, deficient knowledge, risk for impaired skin integrity. Any patient with diabetes is at risk for impaired glucose. Given this patient has dry skin on his feet and a history of diabetes, he is at risk for impaired skin integrity. Education is crucial to prevent skin complications. Since the patient has dry skin, there is concern about a deficiency of knowledge.

LEARNING OBJECTIVE
Skin complications in diabetes are complex and multifactorial. Thus, nurses play a critical role in preventing and managing complications. The primary goal is prevention through education. By emphasizing the importance of skin inspection daily, including cleansing and moisturizing, patients can maintain good hygiene. They need to prevent dryness and avoid excessive moisture.

For correct answer choice:

Administer prescribed pain medication is correct. Pain relief is the top priority in managing renal colic, as severe pain can cause physical and emotional distress. Administration of analgesics (pain medication) will provide relief and improve the patient’s ability to tolerate further interventions.

For incorrect answer choices:

Start IV fluids to prevent dehydration is incorrect. While IV fluids are important in maintaining hydration and potentially aiding stone passage, pain control takes precedence in the acute phase of renal colic.

Monitor for signs of infection is incorrect. Monitoring for infection, such as a urinary tract infection, is important, but it is not the immediate priority compared to controlling severe pain.

Prepare the patient for imaging studies is incorrect. Imaging is necessary to confirm the diagnosis and locate the stone, but it can only be effectively performed after the patient's pain is under control.

For correct answer choice:

Heart rate of 58 bpm is correct. This finding should be reported to the healthcare provider immediately as a heart rate below the normal range for infants (90-110 bpm) indicates bradycardia. This potential sign of Digoxin toxicity necessitates prompt evaluation and potential intervention.

For incorrect answer choices:

Capillary refill time of 2 seconds is incorrect. This is within normal limits for infants, indicating adequate peripheral perfusion. So, this does not require immediate reporting.

Oxygen saturation of 95% is incorrect. This is an acceptable oxygen saturation level for infants, particularly those with congenital heart defects. So, this does not indicate an emergency or the need for intervention.

Potassium level of 4.0 mEq/L is incorrect. This is within the normal range (3.5-5.0 mEq/L). While low potassium levels (hypokalemia) can increase the risk of Digoxin toxicity, a potassium level of 4.0 mEq/L is not concerning.

EXPLANATION
Correct: Gas(flatulence), nausea, decreased appetite, and distended abdomen are signs of constipation. Other signs may include pain and other gastrointestinal symptoms. Patients describe infrequent, hard, and difficult to pass stools.

Incorrect: Bladder obstruction could be considered if the patient complained of lower abdominal pain, pelvic pain, and inability to void along with suprapubic distension. b: GERD symptoms usually include heartburn, belching, etc. d: Opiate reaction usually includes itching, which accompanies nausea or other symptoms. Constipation is a side effect of opioids.

LEARNING OBJECTIVE
In the United States, 33 million adults suffer from constipation. Each year, 92,000 hospitalizations occur as a result. The prevalence is 30% in those over the age of 70.

In the hospital setting, constipation is underrecognized and undertreated. A common cause of constipation in the hospital setting is opioids. It is critical nurses be on the lookout as constipation can have serious complications, including bowel perforation.

Intake and Output include monitoring fluids and bowel movements. The last bowel movements should be included in the sign-off for the next shift.

EXPLANATION

Correct: Hot or cold compresses can reduce pain but are limited to under 20 minutes per application based on patient tolerance. Telling jokes can be used as a distraction technique to reduce pain. Music therapy is used as a relaxation technique.

LEARNING OBJECTIVE
Nurses need to utilize various measures to provide comfort to their patients. Medications help, but patients should not be reliant on pain medications once they leave the hospital. They should be taught ways to reduce pain and anxiety. The following measures can help provide comfort without medication:

• Distraction: Telling jokes, playing games, describing photos, etc.
• Relaxation: Music therapy, meditation, prayer, rhythmic breathing, etc.
• Basic comfort measures: proper positioning, avoiding sudden movements
• Application of cold or heat
• Cutaneous stimulation: TENS unit, acupuncture, massage
• Aromatherapy: moisturizing creams and lotions while avoiding strong smells
• Exercise: Tai Chi, Yoga
• Mind-body therapies: Mediation and mindfulness, Biofeedback
• Therapies: Occupational and Physical

EXPLANATION
Correct: Thiamine, a B vitamin(B1), can cause Wernicke’s encephalopathy(confusion). Left untreated, this condition can cause permanent damage to the brain.

Incorrect:. Folate and MVI are frequently given to alcoholic patients upon admission to the hospital. These patients will often develop a deficiency of folic acid. Generally, they may have poor dietary intake due to their alcohol abuse, so a general multivitamin (MVI) is given also. Other B vitamin deficiencies, such as B6, are also common.

LEARNING OBJECTIVE
Deficient nutritional intake can cause health conditions, and certain health conditions can cause deficiencies, leading to further health problems. Hence, nurses must recognize nutritional imbalances to prevent complications.