A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?
Explain that the need to restrict fluids is the primary limitation.
Advise the client to limit foods that are high in calcium and iron.
Describe the use of an elimination diet to find trigger foods.
Instruct the client to avoid foods with gluten, such as wheat bread.
The Correct Answer is C
Rationale:
A. While some clients may need to manage fluid intake based on their symptoms, it is not the primary dietary restriction for Crohn's disease.
B. Clients with Crohn's disease often need to focus on nutrient-rich foods; limiting calcium and iron is not generally advised unless specific deficiencies are present.
C. An elimination diet can help identify trigger foods that exacerbate symptoms, making this response appropriate and beneficial for managing Crohn's disease.
D. Avoiding gluten is specifically related to celiac disease rather than Crohn's disease, as not all individuals with Crohn's need to eliminate gluten unless they have an associated gluten sensitivity.
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Correct Answer is B
Explanation
Rationale:
A. While deep breathing exercises are important after surgery, they are not specific to cataract extraction recovery; the focus should be on eye care.
B. Observing the pupil response of the right eye can help detect any issues with the right eye post-surgery, ensuring the patient monitors both eyes' health effectively.
C. Clients are generally advised to avoid sleeping flat and may be instructed to sleep in a specific position to prevent pressure on the operated eye, often in a semi-reclined position.
D. Administering a stool softener can be important for some postoperative patients, but it is not a primary concern following cataract surgery unless specifically indicated for that client.
Correct Answer is C
Explanation
Rationale:
A. Observing body language and movement can provide clues about the client's pain but does not directly assess the quality of the pain experienced.
B. Identifying effective pain relief measures is important for managing pain but does not assess the quality of pain itself.
C. Asking the client to describe the pain directly assesses its quality, allowing the nurse to understand its characteristics, such as intensity, duration, and type (e.g., sharp, dull, throbbing).
D. Providing a numeric pain scale is useful for quantifying pain intensity but does not capture the qualitative aspects of the pain experience.