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
Choice A rationale
Restricting fluids is not a primary limitation for clients with Crohn’s disease. Adequate hydration is important for overall health and managing symptoms.
Choice B rationale
Limiting foods high in calcium and iron is not typically recommended for Crohn’s disease. These nutrients are important for maintaining bone health and preventing anemia, which can be concerns for individuals with Crohn’s disease.
Choice C rationale
An elimination diet can help identify trigger foods that may exacerbate symptoms of Crohn’s disease. This approach involves removing certain foods from the diet and gradually reintroducing them to determine which foods cause symptoms.
Choice D rationale
Avoiding gluten is not necessary for all individuals with Crohn’s disease. While some may benefit from a gluten-free diet, it is not a universal recommendation for managing the condition.
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Correct Answer is C
Explanation
Choice A rationale
Increasing the frequency of dressing changes may not be necessary and could potentially disrupt the healing process. The type of dressing used is more important for managing the wound.
Choice B rationale
Leaving the dressing off until consulting with the healthcare provider is not recommended as it can expose the wound to infection and delay healing.
Choice C rationale
Applying a hydrocolloidal gel dressing is appropriate for a stage 3 pressure injury with significant granulation. Hydrocolloidal dressings provide a moist environment that promotes healing and protects the wound from contamination.
Choice D rationale
Replacing the gauze with a transparent dressing may not provide the necessary moisture and protection for a stage 3 pressure injury. Hydrocolloidal dressings are more suitable for this type of wound.
Correct Answer is A
Explanation
Choice A rationale
Irregular rapid heart rate (tachycardia) is a serious side effect of albuterol and warrants immediate intervention. Albuterol is a beta-2 agonist that can cause stimulation of beta-1 receptors in the heart, leading to tachycardia and potential arrhythmias.
Choice B rationale
Uncontrollable shaking (tremors) is a common side effect of albuterol due to its stimulation of beta-2 receptors in skeletal muscles. While uncomfortable, it is not typically life-threatening.
Choice C rationale
Increased anxiety can occur with albuterol use due to its stimulant effects on the central nervous system. However, it is not as immediately dangerous as tachycardia.
Choice D rationale
Throat irritation is a minor side effect of albuterol and does not require immediate intervention.