A home health nurse is conducting a home visit.
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Nurses' Notes
Client is an older adult client with a history of osteoporosis, hypertension, and depression. Client is living independently with help of an aid for housekeeping and laundry. General appearance is neat, hair combed, clothing appropriate for weather. Skin color appropriate for ethnicity, overall skin is dry with bruising and small skin tear noted on knuckle of right hand. Dentures in glass on table. Client reports dentures don't fit well and make their mouth sore. Cough noted while client was drinking juice. Client reports appetite is decreased due to not being very hungry. Client reports eating mostly dinners that adult child prepares and freezes for them. Client states, "I just have to heat them up." Client also states. "Food just doesn't taste good anymore, and have a hard time chewing anything."
osteoporosis
hypertension
depression
independently
clothing appropriate for weather
Cough
appetite is decreased
have a hard time chewing anything.
The Correct Answer is ["C","D","F","G","H"]
Rationale for Risk Factors of Malnutrition in Older Adults
Decreased appetite: A reduced appetite can lead to decreased food intake, which can contribute to malnutrition.
Difficulty chewing: Problems with teeth or dentures can make it difficult to chew food properly, leading to inadequate nutrient intake.
Denture problems: Ill-fitting dentures can make eating uncomfortable and painful, reducing appetite and food intake.
Living independently: Older adults who live alone may have limited access to healthy food, lack cooking skills, or be unable to prepare meals for themselves. This can lead to inadequate nutrition.
Depression: Depression can affect appetite and motivation to eat, leading to decreased food intake and weight loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A negative contraction stress test (CST) indicates that there is no evidence of uteroplacental insufficiency, as the fetal heart rate does not show decelerations with contractions.
B. The number of contractions is not the defining criterion for a negative CST.
C. The absence of accelerations is not related to the interpretation of a CST. The test is focused on fetal heart rate decelerations in response to contractions.
D. Cervical incompetence is not assessed through a contraction stress test; it is typically evaluated through cervical length measurements and history.
Correct Answer is C
Explanation
A. The largest fetal diameter passing through the pelvic outlet would indicate that the fetus has progressed further down the birth canal, beyond 0 station. This usually corresponds to a positive station, where the presenting part is below the ischial spines.
B. The palpation of the posterior fontanel refers to the position of the fetal head, which is not directly related to the station. Station is about the level of the presenting part relative to the ischial spines, not specific to fontanel palpation.
C. A 0 station indicates that the presenting part of the fetus, typically the head in a cephalic presentation, is at the level of the ischial spines. This is a key landmark in labor progression, signifying that the fetal head is engaged in the pelvis.
D. The left occiput posterior (LOP) position refers to the orientation of the fetal head relative to the maternal pelvis, not the station. Station is about the descent of the presenting part, not its orientation.
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