While doing admission assessments, the nurse finds that Mrs. S does not drink; Mrs. X enjoys a glass of wine at supper and bedtime;

Mr. Y has been drinking at least a six-pack of beer every day for the past 20 years and has been ordered by his doctor; and Mr. Z has a cocktail when he goes out to dinner, which is about once a month. Which clients would be considered at nutritional risk?

A) Mrs. X and Mr. Z C) Mrs. X and Mr. Y
B) Mrs. S and Mr. Y D) Mrs. S and Mr. Z


C
Feedback:
Risk begins at more than one drink daily for women and more than two drinks daily for men. The other answers are incorrect because Mrs. S and Mr. Z do not fit the criteria for being at nutritional risk due to alcohol consumption.

Nursing

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The perinatal nurse notes that a newborn's respiratory rate is 68 breaths/minute. What actions by the nurse are appropriate? (Select all that apply.)

A. Auscultating all lung fields (anterior and posterior) B. Documenting the infant's chest measurement C. Inspecting chest for skin color and retractions D. Notifying the physician of the assessment findings E. Withholding oral feedings while the infant is tachypneic

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A client with Cushing's syndrome was taught by the nurse about safety precautions to use at home. Which comment indicates that the client understands the instructions?

1. "I should learn some relaxation exercise so that I do not become suicidal." 2. "I should avoid direct sunlight to prevent my skin from developing dark patches." 3. "I should get up slowly from bed or my chair because I might faint." 4. "I will be careful not to hurt myself, since I could break a bone easily."

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A 39-year-old patient awaits a kidney transplant. Because he must immediately arrange to get to the hospital when a donor kidney is available, it is important that he can be reached anywhere and at any time

To ensure that he receives the message, what type of technology is most effective? a. Internet b. Telecommunications c. WL pager d. CDS

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On admission, the daughter of a stroke victim emphasizes that she only feeds her father nutritional supplements at home because she is afraid he will choke if he eats "real food "and he prefers the supplements

The best response for the nurse would be: 1. "We will be sure that he is evaluated by a nutritionist and speech pathologist while he is here to help you plan his diet.". 2. "Nutritional supplements contain all of the components of a regular diet in liquid form, and are a good option for people who are at risk for aspiration or choking.". 3. "Nutritional supplements are high is salt and sugar content and are not a healthy choice for people who can still eat.". 4. "It's better to give your father what he wants to eat rather than try to force him to eat a healthy diet.".

Nursing