A nurse is assessing an older adult's nutritional status. The nurse understands that which of the following is the most important indicator for a potential nutritional deficit?
Decreased serum albumin levels
Decreased vitamin D levels
Unintentional weight loss,
Anorexia lasting more than 24 hours
The Correct Answer is C
A. Decreased serum albumin levels.
Explanation: Decreased serum albumin levels can be an indicator of poor nutritional status, but they are not as immediate or easily observed as unintentional weight loss.
B. Decreased vitamin D levels.
Explanation: Decreased vitamin D levels may indicate a specific nutrient deficiency but may not capture the overall nutritional status comprehensively.
C. Unintentional weight loss.
Explanation: Unintentional weight loss is a significant indicator of potential nutritional deficits and can be associated with underlying health issues. It can lead to deficiencies in essential nutrients, negatively impacting an individual's overall health and well-being. Weight loss should prompt further assessment and intervention to identify the underlying causes and address nutritional needs
D. Anorexia lasting more than 24 hours.
Explanation: Anorexia (loss of appetite) lasting more than 24 hours may contribute to inadequate nutrient intake, but it is not as direct an indicator as unintentional weight loss, which reflects changes in body composition and overall nutritional status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Tell her to use an assistive device until her balance improves.
Explanation: While using an assistive device may provide support, it is not a comprehensive solution for improving balance. Addressing balance issues usually involves a combination of exercises and interventions tailored to the individual's needs.
B. Provide information on group exercises for balance training.
Explanation: Group exercises specifically designed for balance training can be beneficial for an older adult who is recovering from balance issues and falls. These programs often include exercises targeting stability, coordination, and strength, and they are led by professionals who can provide guidance and supervision. Group exercises also offer a social component, promoting motivation and adherence to the program.
C. Instruct her to enroll in a general exercise program for 8 weeks.
Explanation: A general exercise program may not specifically focus on balance training. Tailoring the program to address balance issues is more appropriate for the client's needs.
D. Help her to learn how to exercise the core group of muscles.
Explanation: While exercising the core muscles can contribute to overall stability, a broader approach that includes balance-specific exercises is preferable for someone recovering from balance issues and falls. Balance training often involves exercises that target various muscle groups involved in maintaining stability.
Correct Answer is B
Explanation
A. Encouraging the client to use a cane when ambulating is a positive preventive measure, promoting stability and support during walking.
B. Keeping the side rails up on the client's bed at night can be concerning.
While it might seem like a safety measure, using side rails can lead to entrapment or falls, especially for frail older adults. Side rails can create a false sense of security, and if the client tries to climb over them or gets caught between the rails, it can result in injury.
C. Keeping several low wattage night lights on in the evening is a good preventive measure, as it helps improve visibility and reduces the risk of falls during nighttime activities.
D. Installing wooden railings on the stairway to the bathroom is a positive preventive measure, enhancing stability and support during stair navigation.
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