Tobacco use is a predisposing factor for cancer of the tongue; the other choices are not. Reduction of Risk

Potential

Immediately postop abdominal surgery, the NG tube keeps the stomach decompressed to prevent surgical-site

disruption and fluid loss through vomiting. Basic Care and Comfort

New prosthetic hips should have an abduction pillow in place to avoid adduction. Basic Care and Comfort

A client with renal insufficiency should not start a low CHO diet because it could result in an increased renal solute load. Clients who have renal disease (renal failure, endstage renal disease [ESRD], dialysis, and transplant) or liver disease (liver failure, hepatic encephalopathy, cirrhosis, transplant, and hepatitis) require some form of protein control in dietary patterns to prevent complications from an inability to handle protein solute load. Proteins used in the diet must be of high biologic value, and protein intake is usually weight based, starting at 0.8 g/kg of dry weight, depending on the client’s underlying clinical condition. Protein levels may be increased as necessary to account for metabolic response to dialysis and regeneration of liver tissue (1.5–2.0 g/kg/day). A minimum level of CHOs are needed in the diet (50–100 g/day) to spare protein. Vitamin and mineral supplements might be indicated with clients who have liver failure. The dietician is instrumental in calculating specific nutrient requirements for these clients and reviewing fluid intake and output, medication profile, and daily weight to monitor client outcomes in conjunction with dialysis technicians and nurses. Physiological Adaptation

The ingestion of nonfood substances (alcohol) can lead to a clinical iron deficiency and might actually be the first sign of a problem. The client might substitute alcohol for a nutrition program that fosters a positive health habit. Physiological Adaptation

There is potential for a lowered pain tolerance to exist with diminished adaptative capacity. Basic Care and

Comfort

Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract. Physiological Adaptation

The client needs to learn how to communicate directly with his wife about her behavior. The nurse’s assistance enables him to practice a new skill and communicates confidence in his ability to confront this situation. Choices 1 and 2 inappropriately direct attention away from the client and toward his wife, who isn’t present. Choice 4 implies that there might be a legitimate reason for the nurse to assume responsibility for something that rightfully belongs to the client. Instead of focusing on his problems, he’ll waste precious time convincing the nurse that he or she should do his work. Psychosocial Integrity

A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward. Basic Care and Comfort

Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy, due to the adjustments that need to be made with the physical alteration of a colostomy. The other diagnoses are not applicable. Reduction of Risk Potential

The spinal change occurring with pregnancy is lordosis. This occurs due to the weight of the enlarging uterus and the affect of gravity. Basic Care and Comfort

A serum creatinine level should be 0.7 to 1.5 mg/dl, and it does not vary with increased protein intake, so it is a better indicator of renal function than the BUN. Physiological Adaptation

Choice 3 not only acknowledges the client’s fear but invites more disclosure and discussion. Reflective listening is very therapeutic and in this case acknowledges the woman’s unspoken fear that she might become depressed like her mother. When her fears have been acknowledged and she feels that the nurse understands, she will be more open to the teaching or interventions to follow. It is a myth that menopause causes depression, but to say that to this client does not acknowledge the fear she shared with the nurse and gives the impression the nurse doesn’t care about her concern. It closes down communication. It is also true that menopause is a normal developmental process. This can certainly be used in teaching but not to address her immediate concern; the client might feel the nurse doesn’t think her concern is appropriate because menopause is normal. If women experience depression during menopause, it is usually due to social stresses such as loss of loved ones, loss of roles, caregiver demands, and physical problems. Choice 4 is true but is a nontherapeutic response in this situation. Health Promotion and Maintenance

Home sources of iron that can be absorbed in the body include meat, poultry, and fish. In addition, these sources contain a factor that helps to enhance iron absorption of nonheme sources. Eating Vitamin C at the same time as iron sources also helps to promote iron absorption. High calcium intake in the diet promotes the absorption of iron because it helps to bind to phytates and thereby limits their effect. Physiological Adaptation

Coffee might cause diarrhea in a client with an ileostomy. The other foods might cause odor. Reduction of

Risk Potential