The nurse identifies the diagnosis Risk for Injury as appropriate ...

[mwit1967]

The nurse identifies the diagnosis Risk for Injury as appropriate for a client with metabolic acidosis. Which strategies should the nurse use to support this diagnosis?
 
  Select all that apply.
  A) Apply wrist restraints and secure to the bed frame.
  B) Discuss chemical restraint use with the healthcare provider.
  C) Keep the bed in the lowest position.
  D) Keep bed side rails raised.
  E) Place a clock and calendar at the bedside.

Question 2

The nurse is caring for a thin, older adult client who is diagnosed with cancer and is receiving aggressive chemotherapy. The client is experiencing severe side effects from the therapy and has lost 10 pounds in the past week.
 
  What should the nurse teach the client to do?
 
  Select all that apply.
  A) Purchase fast foods and prepared foods.
  B) Eat cold foods rather than hot foods, because they are better tolerated.
  C) Keep a food diary and record intake.
  D) Eat large frequent meals high in calories.
  E) Drink liquid supplements to increase intake of nutrients.

[diesoon]

Answer to Question 1

Answer: C, D, E

To reduce the client's risk for injury, the nurse should make sure the bed is kept in the lowest position and the side rails are raised. A clock and calendar at the bedside will help with orientation. Restraints are used in the event the client demonstrates harm to self or others. Confusion or a Risk for Injury is not a reason to use wrist or chemical restraints.

Answer to Question 2

Answer: B, C, E

Nutrition is an essential part of caring for all client with cancer but takes on even greater importance in the frail elderly, who may already have nutritional challenges such as poor dentition, inefficient absorption of nutrients, and mediation side effects. The goal of nutritional teaching is to help the client increase caloric and nutrient intake through the use of liquid supplements, small frequent meals, and a food diary that will help the nurse evaluate strengths and weaknesses of the current plan. The client receiving chemotherapy may tolerate cold foods better than hot foods. Fast foods and prepared foods tend to be high in fat and sodium and are not the best choice because they do not contain adequate healthy nutrients. Instead, involving the family in preparing meals or in enrolling in Meals on Wheels may be better options for easy ways of obtaining meals.