A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?
Diplopia
Hyperproteinemia
Cachexia
Hypermagnesemia
The Correct Answer is C
Choice A Reason:
Diplopia is incorrect. Diplopia is double vision and is not a specific sign of malnutrition.
Choice B Reason:
Hyperproteinemia is incorrect - Malnutrition often leads to hypoalbuminemia (low levels of albumin, a protein), not hyperproteinemia.
Choice C Reason:
Cachexia is correct. Cachexia refers to a state of severe malnutrition and muscle wasting that can occur in individuals with chronic illnesses, especially advanced cancer, heart failure, or certain inflammatory conditions. It is characterized by significant weight loss, muscle atrophy, weakness, and fatigue. Cachexia goes beyond simple malnutrition and is a more severe manifestation of nutritional deficiency.
Choice D Reason:
Hypermagnesemia is incorrect - Malnutrition is more likely to cause deficiencies in minerals like magnesium, not excess levels (hypermagnesemia).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
A calcium level of 11.5 mg/dL is elevated. Normal calcium levels typically range from 8.5 to 10.5 mg/dL. Hypercalcemia can lead to various complications, including cardiac arrhythmias and neurological symptoms. The nurse should notify the provider of this finding for further evaluation and management.Choice B reason
Serum albumin level 3.9 g/dL is not appropriate. This level is within a reasonable range for serum albumin. It might be an indicator of nutritional status, but it's not an urgent concern.
Choice C reason:
Output exceeding intake over a 12-hour period may indicate fluid imbalance or inadequate intake compared to output. However, without further context, such as the client's overall fluid status, this finding alone may not be alarming. The nurse should assess the client's hydration status, consider potential causes of increased output, and address any concerns accordingly. While the nurse may need to monitor closely and address any potential issues, immediate notification of the provider may not be necessary based solely on this finding.Choice D reason:
Fasting blood glucose level 105 mg/dL is not appropriate: A fasting blood glucose level of 105 mg/dL is slightly elevated, but it's not a critically high value. The nurse should monitor blood glucose levels and collaborate with the healthcare team to manage blood glucose appropriately.
However, if the client has a history of diabetes or if there are other concerning factors, such as consistent high glucose levels or symptoms of hyperglycemia, the nurse may need to monitor closely and notify the provider for further evaluation and management. Otherwise, this finding alone may not warrant immediate notification.Correct Answer is A
Explanation
Choice A Reason:
Wearing a lead apron when providing client care is appropriate. When caring for a client who is receiving internal radiation therapy, the nurse should take appropriate safety measures to minimize their exposure to radiation. Wearing a lead apron when providing care to the client helps shield the nurse's body from radiation exposure and reduces the risk of harm.
Choice B Reason:
Allowing visitors to hold the client's hand is inappropriate. Visitors should also be educated about radiation safety measures and should not be encouraged to have close contact with the client during internal radiation therapy.
Choice C Reason:
Leaving the door to the client's room open is inappropriate. Closing the door to the client's room can help contain radiation and limit its spread to other areas.
Choice D Reason:
Placing the dosimeter badge on the client's bed is inappropriate. The dosimeter badge should be worn by healthcare personnel to measure their radiation exposure. Placing it on the client's bed does not accurately measure the nurse's exposure and is not the correct use of the badge.
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