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 D
Explanation
Stage I: Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin. There is no break in the skin, but it may appear red and warm to the touch. It is considered the mildest form of pressure injury, signaling the beginning of potential skin damage.
B) Stage III: Stage III pressure ulcers involve full-thickness skin loss. This means that the damage extends through the dermis into the subcutaneous tissue. There may be visible fat, but bone, tendon, and muscle are not exposed. These ulcers are deeper and more serious than the scenario described.
C) Stage IV: Stage IV pressure ulcers are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. The presence of slough or eschar may be present on some parts of the wound bed, and these ulcers are deep, often with extensive damage and infection.
D) Stage II: Stage II pressure ulcers are characterized by partial-thickness skin loss involving the epidermis and/or dermis. They present as shallow, open ulcers with a red-pink wound bed, without slough. They may also appear as intact or open/ruptured serum-filled blisters, which matches the description given in the scenario. This stage represents a more significant injury than Stage I but does not extend into the deeper layers of skin and tissue as in Stage III and IV.
Correct Answer is A
Explanation
A. Mucous Membranes:
In clients with dark skin, mucous membranes such as the lips, tongue, and gums are the best sites to assess for cyanosis. These areas have less pigmentation and are more vascular, allowing for a more accurate evaluation of oxygenation and the presence of cyanosis.
B. Dorsal surface of the hand:
The dorsal surface of the hand can be used to assess for cyanosis in lighter-skinned individuals, but it is less reliable in dark-skinned clients due to the higher melanin content, which can obscure the bluish tint indicative of cyanosis.
C. Dorsal surface of the foot:
Similar to the dorsal surface of the hand, the dorsal surface of the foot is not an ideal site for assessing cyanosis in clients with dark skin. The presence of melanin can make it difficult to detect changes in skin color.
D. Pinnae of the ears:
The pinnae of the ears are also not the best sites for assessing cyanosis in dark-skinned clients. These areas can be highly pigmented, which can mask the bluish discoloration associated with cyanosis. The mucous membranes remain the most reliable site for this assessment.
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