A nurse in an emergency department is caring for a client.
Which of the following information provided by the client indicates improvement? Select all that apply.
“I have gained 1.8 kg (4 lb) recently, and my BMI is 18.9.”
“My adult child prepares two meals per day for me.”
“My clothing is always clean and appropriate for the weather.”
“I receive three baths per week from a home care aide.”
“I frequently have toothaches and haven’t had dental care in a while.”
“I make eye contact and smile while speaking.”
Correct Answer : A,B,E
The correct answer is choice a, b, e.
Choice A rationale: A recent weight gain of 1.8 kg (4 lb) with a BMI of 18.9 may indicate potential nutritional issues or underlying health problems that require further investigation.
Choice B rationale: Having an adult child prepare meals could suggest the client may have difficulties with meal preparation, possibly due to physical or cognitive limitations.
Choice C rationale: Clean and weather-appropriate clothing indicates the client is managing their personal hygiene and dressing appropriately, which does not typically prompt further assessment.
Choice D rationale: Receiving regular baths from a home care aide suggests the client has support for personal hygiene, which is generally a positive indicator and does not necessitate further assessment.
Choice E rationale: Frequent toothaches and lack of dental care can indicate poor oral health, which can have significant implications for overall health and nutrition, warranting a more detailed assessment.
Choice F rationale: Making eye contact and smiling while speaking generally indicates good social interaction skills and mental well-being, which does not typically prompt further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Administer analgesics on a scheduled basis for the first 24 hr.
This is because the child is at risk for developing peritonitis, which can cause severe abdominal pain.
Scheduled analgesics can provide better pain relief than PRN analgesics.
Choice A is wrong because the child should not be given anything by mouth until bowel sounds return, which can take up to 24 hr after surgery.
Giving clear liquids too soon can cause nausea, vomiting, and abdominal distension.
Choice B is wrong because cromolyn nebulized solution is used to prevent asthma attacks, not to treat appendicitis.
There is no indication that the child has asthma or needs this medication.
Choice C is wrong because applying a warm compress to the operative site can increase inflammation and infection risk.
A cold compress can be used to reduce swelling and pain, but only if prescribed by the provider.
Correct Answer is ["C","F"]
Explanation
Answer is… C and F indicate improvement.
A The client has gained 1.8 kg (4 lb). BMI is 18.9. This is not an improvement because the client’s BMI is still below the normal range of 18.5 to 24.9 The client may have malnutrition or other health problems that affect their weight.
B The clients adult child prepares two meals per day for the client. This is not an improvement because it shows that the client still depends on others for their basic needs and may have difficulty with self-care.
C The clients clothing is clean and appropriate for the weather. This is an improvement because it shows that the client has good hygiene and can dress themselves appropriately.
D The client receives three baths per week from a home care aide. This is not an improvement because it shows that the client still needs assistance with bathing and may have limited mobility or pain.
E The client reports frequent toothaches and lack of dental care. This is not an improvement because it shows that the client has poor oral health and may have infections or other complications.
F The client makes eye contact and smiles when speaking. This is an improvement because it shows that the client has positive mood and social interaction.
: https://www.hopkinsmedicine.org/health/conditions-and-diseases/distal-radius-fracture- wrist-fracture : https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.
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