Answer to Question 1
C
C. Certain conditions increase client's risk of falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss from long bones, cognitive and visual dysfunction, and altered balance increase risk of injury.
A. A diagnosis of diabetes mellitus does not increase the client's risk for injury.
B. A diagnosis of thrombophlebitis does not increase the client's risk for injury.
D. A diagnosis of upper extremity fracture does not increase the client's risk for injury.
Answer to Question 2
B
B. Gastric ileus (decreased or absent peristalsis affecting the stomach but not the intestines), delayed gastric emptying, or gastric resections contraindicate gastric feedings.
A. The general indications for enteral feeding were described in evidenced-based research trends. Some specific examples of these indications include the following: nutritional deficit due to reduced food ingestion or hypermetabolic state, even when clients are physically capable of eating (e.g., confused clients; clients with eating disorders; clients with cancer, sepsis, burns, trauma, or head injury)
C. The general indications for enteral feeding were described in evidenced-based research trends. Some specific examples of these indications include the following: clients who cannot eat because of surgery, injury, or disease process (e.g., comatose clients; clients receiving mechanical ventilation; clients recovering from oral, head, and neck surgeries; clients with pancreatitis or inflammatory bowel disease
D. The general indications for enteral feeding were described in evidenced-based research trends. Some specific examples of these indications include the following: nutritional deficit due to reduced food ingestion or hypermetabolic state, even when clients are physically capable of eating (e.g., confused clients; clients with eating disorders; clients with cancer, sepsis, burns, trauma, or head injury).
Mechanical ventilation may be necessary for clients experiencing respiratory alkalosis
Vital signs for clients in metabolic alkalosis may reveal hypotension, bradycardia, and an irregular
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
Testing client’s ability to identify sharp sensations
Testing the client’s ability to feel vibrations, the toe