a nurse is completing an admission assessment on an adolescent client who is a vegetarian he eats milk products but does not like beans which of the f

ATI RN

ATI Nutrition

1. A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet?

A. Peanut butter and jelly sandwich
B. Baked potato topped with sour cream
C. Bagel with cream cheese
D. Fruit salad

Correct answer: D

Rationale: The correct answer is 'Fruit salad.' Since the adolescent client is a vegetarian who eats milk products but does not like beans, suggesting a fruit salad for lunch would provide essential nutrients like vitamins, minerals, and fiber that are commonly found in fruits. Fruit salad can help supplement the nutrients that may be lacking in his diet. Choices A, B, and C do not offer the same variety and quantity of nutrients as a fruit salad, making them less optimal choices for meeting the client's dietary needs.

2. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

A. Ensure that the bed linen is always dry
B. Frequently check the bed for wetness and keep it dry
C. Place a rubber sheet under the client's buttocks
D. Keep the patient clean and dry

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

3. Thiamin

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B12

Correct answer: A

Rationale: Thiamin, or Vitamin B1, plays a crucial role in energy metabolism and the proper functioning of the nervous system.

4. A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI?

A. A client with a weight of 128 lb and height of 70 inches
B. A client with a weight of 150 lb and height of 68 inches
C. A client with a weight of 200 lb and height of 72 inches
D. A client with a weight of 133 lb and height of 60 inches

Correct answer: A

Rationale: To determine a healthy BMI, we need to calculate it using the formula: BMI = weight (lbs) / height^2 (inches) x 703. For choice A, BMI = 128 / (70 x 70) x 703 = 18.38, which falls within the healthy BMI range of 18.5-24.9. Therefore, choice A is correct. Choices B, C, and D have BMIs of 22.8, 27.1, and 26.1, respectively, which are outside the healthy range. Thus, choices B, C, and D are incorrect.

5. Why is a pulse oximeter attached to Mr. Dizon's finger?

A. To determine if the patient's hemoglobin level is low and if he requires a blood transfusion
B. To check the level of the patient's tissue perfusion
C. To measure the effectiveness of the patient's anti-hypertensive medications
D. To detect oxygen saturation of arterial blood before symptoms of hypoxemia develop

Correct answer: D

Rationale: A pulse oximeter is used to detect the oxygen saturation levels in arterial blood before the onset of hypoxemia symptoms. This device provides essential information about the effectiveness of oxygen transportation to the body's tissues. Choice A is incorrect because a pulse oximeter does not directly measure hemoglobin levels nor determine the need for a blood transfusion. Choice B is incorrect because a pulse oximeter is designed specifically to assess oxygen saturation, not tissue perfusion. Choice C is incorrect because a pulse oximeter is not used to measure the efficacy of anti-hypertensive medications, but rather to monitor oxygen levels in the blood.