A patient with Alzheimer's disease has lost 5 pounds over the past month. What is the best nursing intervention to address this weight loss?
1. Provide a high-fiber diet.
2. Recommend referral to a nutritionist for tube feeding.
3. Make sure the patient is put on a mechanical soft diet.
4. Give the patient food choices from which to select.
1
Rationale 1: Nutritional goals include reducing constipation, which is addressed with a high-fiber diet and maintaining hydration.
Rationale 2: There is no indication that tube feeding is required at this point.
Rationale 3: There is no indication of a problem with the patient's teeth or chewing/swallowing mechanisms.
Rationale 4: Because of altered mental status, the patient might or might not be able to state what food choices he or she prefers.
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A nurse is performing a nursing assessment for a 59-year-old man who is hypertensive. What is the rationale for including questions about prescribed medications and their effects on sexual function in the assessment?
a. Sexual dysfunction may result from use of prescription and nonprescription drugs. b. Such questions are an indirect way of learning about the patient's drug adherence. c. These questions ease the transition to questions about sexual practices in general. d. Sexual dysfunction can cause stress and contribute to increased blood pressure.
A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?
A) Over the lower arm B) Brachial artery C) Over the client's thigh D) Radial artery
The nurse is completing a respiratory assessment on a newborn. What are normal findings of the assessment the nurse should document? (Select all that apply.)
a. Periodic breathing b. Respiratory rate of 40 breaths/min c. Wheezes on auscultation d. Apnea lasting 25 seconds e. Slight intercostal retractions
The nurse would be most alert for assessment findings of hypovolemic shock in which patient?
1. Patient who had a DVT after a surgical procedure 2 years ago 2. Patient 6 hours postmastectomy 3. Patient with coronary atherosclerosis who takes 81 mg of aspirin daily 4. Patient sustaining a transmural myocardial infarction 2 days ago