A nurse is evaluating the meal choices of a client who has major depressive disorder and a prescription of Phenelzine. Which of the following selections should the nurse identify as appropriate?

Correct Answer: C

Rationale: In this scenario, the nurse should identify option C, which is strawberry yogurt, as the appropriate choice for the client with major depressive disorder and a prescription of Phenelzine. Phenelzine is a monoamine oxidase inhibitor (MAOI) that requires dietary restrictions to prevent interactions that can lead to hypertensive crisis. Foods high in tyramine, such as aged cheeses (option A - cheddar cheese), smoked or pickled fish (option B - smoked salmon), and processed meats (option D - pepperoni pizza) should be avoided as they can interact with MAOIs. Educationally, this question highlights the importance of understanding dietary restrictions when managing clients on specific medications. It emphasizes the need for nurses to be knowledgeable about drug-nutrient interactions to ensure client safety and optimal treatment outcomes. By selecting the appropriate choice, nurses demonstrate their competence in applying pharmacological principles to nutritional management in a clinical setting.

Correct Answer: C

Rationale: The correct answer is C) Measure the stomach aspirate prior to the feeding. This action is crucial because it helps ensure proper placement of the nasogastric tube in the stomach. In preterm newborns, correct tube placement is essential to prevent complications such as aspiration. By measuring the stomach aspirate, the nurse can confirm that the tube is in the stomach and not in the lungs or esophagus. Option A, stabilizing the tube with tape to the newborn's forehead, is incorrect as this does not address the proper placement of the tube and may cause discomfort or skin irritation to the newborn. Option B, removing supplemental oxygen during the feeding, is incorrect as it could compromise the newborn's respiratory status, especially if they require oxygen support. Option D, placing the newborn on her left side for 30 min after the feeding, is incorrect as there is no evidence to support this practice for gavage feeding administration. In an educational context, understanding the importance of proper nasogastric tube placement and aspiration assessment is crucial for nurses caring for neonates. This knowledge ensures safe and effective feeding practices, reducing the risk of complications and promoting optimal patient outcomes.

Correct Answer: C

Rationale: In the context of dumping syndrome following gastric surgery, it is crucial for the client to consume a protein source with each meal. Protein helps slow down gastric emptying, which can reduce the severity of dumping syndrome symptoms such as diarrhea, dizziness, and weakness. By choosing option C, the client demonstrates an understanding of the importance of protein in managing their condition. Option A is incorrect because drinking additional fluids with meals can actually worsen dumping syndrome by rapidly increasing gastric volume and exacerbating symptoms. Option B is also incorrect as high-fiber snacks between meals can further aggravate dumping syndrome due to their potential to speed up gastrointestinal transit. Option D is incorrect as caffeinated beverages can stimulate gastric acid secretion and worsen symptoms of dumping syndrome. It is important to educate clients to avoid caffeinated beverages in order to manage their condition effectively. In an educational context, it is essential for nurses to provide clear and accurate information to clients experiencing dumping syndrome to help them make informed choices that promote their health and well-being. Understanding the rationale behind dietary recommendations can empower clients to take an active role in managing their condition and improving their quality of life post-gastric surgery.

Correct Answer: D

Rationale: In this scenario, option D, which states "Flush the client's tube with 30 mL of water every 4 hr," is the correct action for the nurse to take when initiating continuous enteral feedings for a client with a new gastrostomy tube. This action is crucial because flushing the tube with water helps prevent clogging and ensures proper tube patency, which is essential for the delivery of enteral feedings. Regular flushing also helps maintain tube integrity and reduces the risk of infection. Regarding the incorrect options: - Option A (Measure the client's gastric residual every 12 hr) is not the immediate action needed when initiating continuous enteral feedings. Checking residual volumes is important but typically done before feedings to assess tolerance. - Option B (Obtain the client's electrolyte levels every 4 hr) is excessive and not necessary at this frequency for a client with a new gastrostomy tube unless there are specific indications. - Option C (Keep the client's head elevated at 15* during feedings) is a general recommendation for preventing aspiration during feedings but is not directly related to the immediate action of tube flushing. Educationally, understanding the importance of tube maintenance, such as regular flushing, is essential for nurses caring for clients with enteral feeding tubes. It ensures safe and effective delivery of nutrition and helps prevent complications associated with tube malfunctions.

Correct Answer: A

Rationale: In teaching about manifestations of hypoglycemia, it is crucial to highlight that blurred vision is a common symptom. This is because hypoglycemia impairs the function of the eyes due to decreased glucose supply to the optic nerves, leading to visual disturbances. By experiencing blurred vision, individuals may recognize this early warning sign and take necessary actions to manage their blood sugar levels promptly. In contrast, vomiting is more commonly associated with conditions like food poisoning or gastrointestinal issues rather than hypoglycemia. Kussmaul respirations are deep and rapid breathing patterns typically seen in diabetic ketoacidosis, a complication of uncontrolled diabetes, not hypoglycemia. Bradycardia, or a slow heart rate, is not a typical manifestation of hypoglycemia as the body usually responds to low blood sugar levels by increasing heart rate to compensate for the lack of energy. Educationally, emphasizing the specific signs and symptoms of hypoglycemia helps healthcare professionals differentiate it from other conditions, enabling timely and appropriate interventions. Understanding these distinctions is crucial for providing safe and effective patient care, especially for individuals with diabetes or those at risk of hypoglycemia.