Nursing interventions appropriate for the client with the nursing diagnosis Imbalanced Nutrition: Less than Body Requirements include:
1. Assisting with changes in diet.
2. Monitoring blood glucose.
3. Providing enteral nutrition.
4. Feeding the client.
1
Rationale: The client might need to make diet changes, and the nurse provides client teaching to reinforce the need for the diet.
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A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when this vein is removed?" The nurse should reply:
a. "Venous insufficiency is a common problem after this type of surgery." b. "Oh, you have lots of veinsâ€"you won't even notice that it has been removed." c. "You will probably experience decreased circulation after the vein is removed." d. "This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition."
Paradoxical chest wall movement in a patient with multiple fractured ribs of the right thorax is characterized by
a. expansion of the thorax upon inspiration while the injured area of the chest wall is depressed. b. bulging of the intercostal spaces during inspiration on the side of the injury. c. unilateral expansion with no expansion on the side of the injury. d. shallow respirations on the side of the injury.
The nurse reminds a group of CNAs that for a patient with an elevated temperature, the quickest and simplest technique to reduce the temperature is to:
a. apply ice packs to the groin. b. bathe in tepid water. c. remove clothing and bed linen. d. give chilled drinks.
Reality orientation is
A. orienting a patient to time, place, and person with visual reminders or verbal cues. B. a form of therapy designed to restore a confused individual to her original mental state. C. only performed by licensed personnel with a physician's order. D. a means of accepting and validating the patient's beliefs.