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 ["A","C","D","E"]
Explanation
Rationale:
A. Performing hand hygiene is crucial to prevent the spread of infection before any patient interaction or procedure.
B. Brushing the client’s teeth is not necessary before applying an oxygen mask and does not pertain to immediate care.
C. Checking the skin around the face is important to ensure there are no irritations or breakdowns that could affect the mask's fit and the patient's comfort.
D. Identifying the client using 2 identifiers is a critical safety step to ensure the correct patient receives the intended care.
E. Assessing respiratory function is important to determine the severity of the client’s condition and the appropriate oxygen delivery method.
F. Donning gloves is not required for applying a simple face mask unless there is potential for contact with blood or bodily fluids.
G. Determining if the client needs to go to the bathroom is not directly related to applying the face mask and should be assessed but is not critical before mask application.
Correct Answer is A
Explanation
Rationale:
A. HIV primarily targets and destroys helper T-cells (CD4 cells), which are crucial for orchestrating the immune response, leading to immune system suppression and increased vulnerability to infections.
B. An increase in B-lymphocytes and IgM is not a direct action of HIV; in fact, B-cell function is also impaired as the disease progresses.
C. Proliferation of suppressor T-cells is not a characteristic effect of HIV; instead, it is the helper T-cells that are predominantly affected, leading to immune dysfunction.
D. While cytotoxic T cells may be present, their function is impaired due to the loss of helper T-cells, but deficiency of cytotoxic T cells is not the primary mechanism by which HIV suppresses the immune system.