A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status?
Accessibility
Food preparation
Food preferences
Finances
The Correct Answer is A
A) Accessibility:
Accessibility refers to the client's ability to obtain food, which is crucial for nutritional status, especially for someone who lives alone and cannot drive. Difficulty in accessing grocery stores or markets can limit the variety and availability of nutritious food options, potentially leading to poor nutritional intake.
B) Food preparation:
Food preparation skills are important, but if the client has difficulty accessing food in the first place (due to transportation limitations), their ability to prepare meals becomes secondary. Accessibility to food sources is a more immediate concern for nutritional status.
C) Food preferences:
While food preferences can influence dietary choices, the ability to access food is a more fundamental issue that directly impacts nutritional intake, especially for someone who lives alone and has limited mobility.
D) Finances:
Financial constraints can certainly affect food choices and access to nutritious options. However, in this scenario, the primary concern is the physical accessibility to food sources, which directly impacts the client's ability to maintain adequate nutrition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
(a) Soles of the feet:
The soles of the feet are not considered the most reliable indicator of central cyanosis because peripheral areas can be affected by various factors, including temperature and circulation. Changes in color here might not accurately reflect central oxygenation status.
(b) Oral mucosa:
The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygenation status of the central circulatory system. Cyanosis in this area indicates a significant drop in arterial oxygen saturation and is a more direct indicator of hypoxemia compared to peripheral sites.
(c) Ear lobes:
Ear lobes, like the soles of the feet, can be influenced by peripheral circulation and environmental factors. While cyanosis can be observed here, it is not as reliable as central sites like the oral mucosa for assessing systemic oxygenation.
(d) Conjunctivae:
The conjunctivae can show signs of cyanosis, but the oral mucosa is still a more sensitive and reliable indicator for central cyanosis. The oral mucosa provides a clear and consistent site to assess oxygenation in emergency situations.
Correct Answer is C
Explanation
A. Acanthosis Nigricans:
Acanthosis nigricans is characterized by dark, velvety patches of skin, often found in body folds such as the neck, armpits, and groin. It does not present as the yellow discoloration seen in the photo.
B. Cyanosis:
Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. The image shows yellow discoloration, not the blue tint associated with cyanosis.
C. Jaundice:
Jaundice is indicated by a yellowish tint to the skin and sclera due to elevated bilirubin levels, commonly associated with liver dysfunction. The photo clearly shows this yellow discoloration, consistent with jaundice, often seen in chronic alcoholics with liver disease.
D. Carotenemia:
Carotenemia presents as a yellow-orange discoloration of the skin, especially on the palms and soles, due to high levels of carotene in the blood. It does not typically affect the sclera, which differentiates it from jaundice. The uniform yellowing of the skin and eyes in the photo aligns more with jaundice.
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