A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?
How many popsicles are available.
The color and flavor of gelatin used.
If the popsicles are completely frozen.
Whether they contain pulp or fruit.
The Correct Answer is C
Choice A rationale
Knowing how many popsicles are available is not relevant to the nurse’s assessment. The focus should be on the content and preparation of the popsicles to ensure they meet the clear liquid diet requirements.
Choice B rationale
The color and flavor of the gelatin used in the popsicles are not as important as ensuring the popsicles meet the clear liquid diet requirements. The nurse should focus on the preparation and content of the popsicles.
Choice C rationale
Ensuring the popsicles are completely frozen is important to adhere to the clear liquid diet recommendation. If the popsicles are not completely frozen, they may contain solid particles or ingredients that could worsen the child’s condition.
Choice D rationale
Whether the popsicles contain pulp or fruit is important to determine if they meet the clear liquid diet requirements. Popsicles with pulp or fruit do not qualify as clear liquids and could worsen the child’s condition.
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Correct Answer is D
Explanation
Choice A rationale
Determining the client’s activity tolerance is important but should follow the initial assessment of the client’s ability to perform ADLs safely.
Choice B rationale
Teaching the client to shorten the stride to prevent falls is not necessary if the client’s gait is smooth and steady. This intervention is more appropriate for clients with gait instability.
Choice C rationale
Initiating a fall risk protocol for the client is not necessary if the client’s gait is smooth and steady. This protocol is more appropriate for clients with a higher risk of falls.
Choice D rationale
Recording the client’s ability to perform ADLs safely is the next appropriate action. This documentation is essential for the care plan and ensures that the client’s current status is accurately reflected.
Correct Answer is C
Explanation
Choice A rationale
Inspecting crutches to ensure rubber tips are intact is important for safety, but it does not indicate an understanding of proper crutch walking technique. Proper crutch walking involves more than just equipment inspection.
Choice B rationale
Practicing bicep and triceps isometric exercises can help strengthen the muscles needed for crutch walking, but it does not directly demonstrate an understanding of the correct crutch gait. The focus should be on the actual technique of using the crutches.
Choice C rationale
Bearing body weight on the palms of hands during the crutch gait is the correct behavior that indicates an understanding of proper crutch walking. This technique helps distribute weight appropriately and prevents strain on the underarms, which can cause nerve damage and discomfort.
Choice D rationale
Progressing to foot touchdown and weight bearing of the affected leg is not appropriate for a three-point gait, which is used when the client should not bear any weight on the affected leg. This choice indicates a misunderstanding of the correct crutch walking technique for this specific gait.