A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)
Encourage the client to look at the balance beam
Have the client wear the same clothing every day.
Weigh the client at the same time in the morning
Use the same scale to weigh the client.
Discuss the client's weight with her after each measurement.
Correct Answer : B,C,D
A) Encourage the client to look at the balance beam:
Encouraging the client to look at the balance beam may help her feel more engaged in the process of weight measurement. This can foster trust and cooperation during what may be a challenging procedure due to her history of Anorexia and Bulimia Nervosa.
B) Have the client wear the same clothing every day:
Consistency in clothing helps to minimize variations in weight measurements that could be attributed to changes in clothing weight rather than actual body weight fluctuations. This practice ensures more accurate and reliable serial weight measurements.
C) Weigh the client at the same time in the morning:
Weighing the client at the same time each day helps to standardize conditions and minimize daily variations due to factors like hydration levels and food intake, providing more accurate serial weight measurements.
D) Use the same scale to weigh the client:
Using the same scale ensures consistency in measurement accuracy. Different scales can yield slightly different readings, which could affect the interpretation of weight trends over time.
E) Discuss the client's weight with her after each measurement:
While discussing weight may be part of the client's care plan, it's not necessarily a standard action during the process of conducting serial weight measurements. The focus during the actual weighing process should be on maintaining consistency and accuracy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Intercostal spaces:
Assessing intercostal spaces typically involves palpating or inspecting the area between the ribs to check for abnormalities such as retractions or tenderness, usually conducted with the client sitting or standing.
B) Lymph nodes:
Palpation of lymph nodes, such as in the cervical region, involves using fingertips to gently feel for enlarged or tender nodes. This examination focuses on areas like the neck, underarms, and groin.
C) Skin Turgor:
The image depicts a nurse pinching the skin, likely on the chest or forearm, which is a common method to assess skin turgor. Skin turgor evaluation helps determine hydration status; if the skin remains tented and returns slowly to its original position, it indicates dehydration.
D) Carotid Pulse:
Assessing the carotid pulse involves palpating the carotid artery along the side of the neck to evaluate the strength and rhythm of the pulse. This is typically done using the pads of the fingers, not by pinching the skin.
Correct Answer is C
Explanation
A) Snellen chart:
The Snellen chart is used to assess distance vision, not near vision. It consists of letters or symbols arranged in rows, with the client typically asked to read from a specific distance to test visual acuity.
B) Penlight:
A penlight is primarily used to assess pupillary reactions and near vision tasks such as accommodation. It helps examine how the pupils respond to light and how well the eyes focus on near objects.
C) Magazine:
A magazine or similar reading material is commonly used to assess near vision. Clients are asked to read the text at a comfortable distance, evaluating their ability to focus on close-up objects and the clarity of their vision.
D) Ophthalmoscope:
An ophthalmoscope is used to examine the interior structures of the eye, such as the retina and optic nerve head. It is not used for assessing near vision but rather for diagnosing conditions affecting the eye's internal structures.
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