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A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?

Diplopia

Hyperproteinemia

Cachexia

Hypermagnesemia

Answer and Explanation

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).

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Correct Answer is A

Explanation

Choice A reason:

Obtaining consent for surgery is the correct answer. Obtaining informed consent for surgery is a critical and ethical step to ensure the client's rights are respected and that necessary medical interventions can be performed. However, in cases where the client is unable to provide consent due to their level of intoxication, the nurse should follow established protocols for obtaining consent from a legal guardian or

Choice B reason:

Insert an NG tube is incorrect. Inserting a nasogastric (NG) tube might be a necessary step in preparing a client for surgery in certain cases, but it is not the top priority in this situation. Obtaining consent for surgery takes precedence.

Choice C reason:

Applying ant embolic stockings is incorrect. Applying ant embolic stockings, also known as compression stockings, is an important measure to prevent blood clots (deep vein thrombosis) during and after surgery. However, obtaining consent for surgery is more urgent in an emergency situation.

Choice D reason:

Inserting an indwelling urinary catheter is incorrect. Inserting a urinary catheter might be necessary to monitor the client's urinary output during surgery, but obtaining consent for surgery is the priority action.

A. A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% B. A client who has multiple sclerosis and reports ataxia and vertigo C. A client who has left-sided paralysis and slurred speech from a prior stroke D. A client who has thrombocytopenia and reports a nosebleed

Correct Answer is A

Explanation

Choice A Reason:

A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% is correct. The nurse should attend to the client with chronic obstructive pulmonary disease and an oxygen saturation of 89% first. Oxygen saturation levels below 90% indicate significant hypoxemia and potential respiratory distress. The client with COPD is at risk for further worsening of their condition due to inadequate oxygenation. Therefore, addressing this client's low oxygen saturation is a priority to ensure their respiratory status is stabilized.

Choice B Reason:

A client who has multiple sclerosis and reports ataxia and vertigo is incorrect. While these symptoms need assessment and care, they are not indicative of an immediate life-threatening situation.

Choice CReason:

A client who has left-sided paralysis and slurred speech from a prior stroke is incorrect., While this client requires ongoing care, the immediate concern is lower in priority compared to addressing severe hypoxemia.

Choice DReason:

A client who has thrombocytopenia and reports a nosebleed is incorrect. Although a nosebleed can be concerning due to thrombocytopenia, it is not as immediately critical as addressing severe hypoxemia.

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A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?

Nursing Test Bank

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