A nurse who is using a 24-hour recall method for obtaining data about a client's dietary intake would be aware that which of the following is true?
1. Most clients accurately recall the exact amounts of various foods eaten.
2. The previous day's intake may not represent the usual intake.
3. Virtually all clients provide thorough and accurate information.
4. Clients have a tendency to overestimate intake as the portion size increases.
ANS: 2
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A client has been receiving tube feeds for the past several days. The client's plan of care identifies the nursing diagnosis Risk for Fluid Imbalance. How should this risk be best mitigated?
A) Ensure the client adheres to the correct fluid restriction while receiving feeds. B) Use the smallest amount of water necessary to flush the tube after feeds or medications. C) Administer supplementary water after considering the quantity of feeds and flushes. D) Aspirate the stomach contents if the client develops peripheral edema.
When planning care for children, the nurse knows which of the following factors has the largest impact but is not able to be altered to influence the growth and development of children?
A) Environment B) Genetics C) Socialization D) Family
The nurse cares for a client with an AV fistula for hemodialysis. Which assessments will the nurse perform when assessing the AV fistula? Select all that apply.
A. Palpation B. Auscultation C. Inspection D. Percussion
After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome?
a. Decreased motor activity b. Confusion and disbelief c. Flashbacks and dreams d. Fears and phobias