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. Storing the medication at room temperature is appropriate and indicates correct understanding.
B. Priming the inhaler with 7 pumps is excessive. Generally, ipratropium inhalers require only 2-3 pumps to prime before first use, indicating that the client needs additional teaching on the proper priming technique.
C. Attaching a spacer device is a beneficial action that can enhance medication delivery and is recommended for use with metered-dose inhalers.
D. Rinsing the mouth after each use is good practice to minimize the risk of oral side effects, such as dryness or irritation.
Correct Answer is B
Explanation
Rationale:
A. Increasing the frequency of dressing changes is not necessary unless there is excessive drainage or signs of infection; it may disrupt the healing process.
B. Applying a hydrocolloidal gel dressing is appropriate for a stage 3 pressure injury with granulation tissue as it promotes a moist healing environment and helps facilitate healing.
C. A transparent dressing may not provide adequate moisture retention or protection for a stage 3 pressure injury compared to a hydrocolloidal dressing.
D. Leaving the dressing off could expose the wound to infection and is not advisable without further assessment and consultation.