A client requires a full-thickness graft to cover a chronic wound. How is the donor site selected?

Choice A rationale

Coping strategies are relevant to overall health and well-being, but they are not directly related to nutritional assessment. Nutritional assessments focus on physical and dietary data rather than psychological coping mechanisms.

Choice B rationale

Wrist circumference can be used as an anthropometric measure of body frame size, but it is not a standard parameter in a comprehensive nutritional assessment. More common measurements include height, weight, and BMI.

Choice C rationale

Clinical examination findings are critical in nutritional assessments to identify physical signs of malnutrition, such as muscle wasting, edema, or skin changes. These observations help assess the client’s nutritional status and needs.

Choice D rationale

BMI (Body Mass Index) is a widely used indicator of body fat based on height and weight. It helps classify individuals into categories like underweight, normal weight, overweight, or obese, providing insight into nutritional health.

Choice E rationale

Dietary data, including food intake, preferences, and restrictions, are essential components of a nutritional assessment. Understanding a client's dietary habits allows the nurse to identify nutritional deficiencies or excesses and plan appropriate interventions

Choice A rationale

Pinpoint pupils can indicate opioid use or damage to the pons, a part of the brainstem. This finding warrants further evaluation to determine the underlying cause and appropriate intervention.

Choice B rationale

Absence of pupillary response suggests severe brain injury or brainstem dysfunction. It is a critical finding that requires immediate medical attention to address potential life-threatening conditions.

Choice C rationale

Pupil reaction to light is a normal response indicating intact cranial nerve function. This finding does not raise neurologic concerns and does not require further investigation.

Choice D rationale

Quick pupil reaction is a normal response and indicates healthy cranial nerve function. This finding is not associated with neurologic concerns.

Choice E rationale

Unequal pupils, or anisocoria, can indicate increased intracranial pressure, brain injury, or nerve damage. This finding requires prompt assessment and intervention to prevent further complications.