A client in a health care facility is placed on a mechanical soft diet. The client may choose to eat:
A. Salad
B. Baked potato without skin
C. Cooked cereal
D. Soft peeled apples
C
C. Mechanically Altered: moist, soft texture, and easily forms a bolus.
A. Regular diet with no restrictions
B. Dysphagia Advanced: regular food (with the exception of very hard, sticky, or crunchy foods)
D. Dysphagia Advanced: Regular food (with the exception of very hard, sticky, or crunchy foods)
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An instructor explains that patients may need a nurse's assistance to help cope with the stress of hospitalization. The nurse validates understanding by
1. Using appropriate humor therapy. 2. Providing a back massage and other comfort measures to help the patient relax. 3. Explaining what the patient should expect before performing a procedure or treatment. 4. All of the above.
The nurse visits the foster home of a newborn with failure to thrive syndrome. Which observation indicates a successful outcome for this child's care?
A) Birth mother has stopped visiting the child. B) Birth father comes by the home to bring toys. C) Child eagerly takes a bottle and is gaining weight. D) Child is crying and has bruises over the lower legs.
Following an assessment of a patient, the nurse identifies the nursing diagnosis Activity Intolerance r/t Increased Weight Gain and Inactivity. The physician wants the patient to improve her endurance and increase activity. Which of the following is an outcome identified by the nurse?
A) Resting heart rate will be 90-100/minute B) Blood pressure will be maintained between 140/80 and 160/90 C) Exercise will be performed 3 times per day over the next 2 weeks D) Accommodation will be made for excess weight and fatigue
A client tried to gouge out his eye in response to auditory hallucinations commanding, "If thine eye offend thee, pluck it out." The nurse would analyze this behavior as indicating:
1. Impaired impulse control 2. Inability to manage anger 3. Derealization 4. Inappropriate affect