A client lost 35 pounds over the past 3 months on a very low-carbohydrate diet. What physical sign should suggest to the nurse that this client is experiencing a vitamin deficiency?
a. Swollen, shiny tongue
b. Generalized skin lesions
c. Reddened, bleeding gums
d. Difficulty maintaining balance
c. Reddened, bleeding gums
Reddened, bleeding gums are a precursor to scurvy, a deficiency of vitamin C which is found in fresh fruits and vegetables. An individual who is on a very low-carbohydrate diet will refrain from eating fruits and vegetables and would need a vitamin supplement. If a supplement is not used, a vitamin C deficiency might develop. Skin lesions, or dermatitis, are a potential sign of vitamin B-6 deficiency. A shiny, swollen tongue, or glossitis, is associated with a riboflavin (B-2) deficiency. Balance problems, or ataxia, result from a thiamine (B-1) deficiency. The B vitamins are readily available in high-protein foods which are consumed on a very low-carbohydrate diet.
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When developing a plan of care for the client with paranoid personality disorder, the nurse recognizes that a hallmark of the disorder is the client's:
1. impulsive behavior. 2. difficulty with interpersonal relationships. 3. preoccupation with delusions of persecution. 4. violation of the rights of others.
According to the nursing role effectiveness model, which of the following would affect the nurse's ability to engage effectively in an activity, such as giving a patient a back rub to help promote sleep?
a. Dependent role functions b. Execution of medical orders c. Nurse-physician relationship d. Patient acuity level
The nurse walks into her patient's room to find him unresponsive. She begins CPR, knowing that during a "code" situation, chest compressions should be interrupted for which of the following situations? (Select all that apply.)
a. Ventilation b. Pulse checks c. Intubation d. Defibrillation
The parent of a 4-year-old brings the child to the clinic and tells the nurse the child's abdomen is distended. After a complete examination, a diagnosis of Wilms tumor is suspected. Which of the following is most important when doing a physical examination on this child?
1. Avoid palpation of the abdomen. 2. Assess the urine for the presence of blood. 3. Monitor vital signs, especially the blood pressure. 4. Obtain an accurate height and weight.