A nurse in a provider's office is caring for a client.
Click to highlight the findings that indicate malnutrition. To deselect a finding, click on the finding again.
Nurses' Notes
Today.
Client presents to the office with their adult daughter. Daughter states the client's forgetfulness has increased. She states. "I often notice uneaten meals in the microwave when I come over to visit." Daughter also reports that the client fell 1 month ago and has a wound on their leg that won't heal. On assessment skin is rough and dry, lungs are clear bilaterally, abdomen is soft and concave, and edema noted to the face and lower extremities.
Vital Signs
Today
- Temperature 37.7° C (98.9° F)
- Heart rate 103/min
- Respiratory rate 16/min
- Blood pressure 102/68 mm Hg
- Weight 65.9 kg (145 lb)
uneaten meals
wound on their leg that won't heal
skin is rough and dry
edema noted to the face and lower extremities
Weight 65.9 kg (145 lb)
The Correct Answer is ["A","B","C","D"]
- Uneaten meals suggest that the client is not consuming the food provided, which can lead to inadequate intake of nutrients and calories, thus indicating possible malnutrition.
- A wound that won't heal can be a sign of malnutrition, as proper nutrition is essential for wound healing and maintenance of skin integrity.
- Rough and dry skin can be indicative of malnutrition, particularly if there is a deficiency in essential fatty acids and other nutrients that maintain skin health.
- Edema to the face and lower extremities can be a sign of protein-energy malnutrition, where the body does not get enough protein to maintain plasma oncotic pressure, leading to fluid accumulation in tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Having someone remain with the client for 30 minutes after meals can provide support and encouragement to prevent purging behaviorwhich are common with bulimia andnot anorexia nervosa.
B. Offering a selection of beverages at each meal may not directly address the underlying issues associated with anorexia nervosa.
C. Informing the client of a specific weight gain expectation may increase anxiety and may not be appropriate given the individualized nature of weight restoration in anorexia nervosa
treatment.
D. Encouraging the client to participate in developing dietary goals is important for fostering autonomy and empowerment and is associated with better compliance.
Correct Answer is C
Explanation
A. Encouraging the client to eat even if nauseated may worsen nausea and discomfort. It's essential to respect the client's feelings of nausea and provide strategies to alleviate symptoms before eating.
B. Serving hot foods at mealtime may exacerbate nausea in some individuals. It's generally recommended to serve foods at room temperature or slightly chilled to minimize nausea.
C. Providing low-fat carbohydrates with meals, such as crackers or bread, can help settle the stomach and provide easily digestible energy. Complex carbohydrates are less likely to exacerbate nausea compared to fatty or spicy foods.
D. Limiting fluid intake between meals may help reduce nausea in some individuals, but it's important to ensure adequate hydration throughout the day. Encouraging small, frequent sips of clear fluids may be beneficial for managing nausea and preventing dehydration.
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