A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?
Heart rate 89/min.
Pink mucous membranes.
Pallor with scaly skin.
Body mass index 23.
The Correct Answer is C
The correct answer is choice C. Pallor with scaly skin.
Choice A rationale:
"Heart rate 89/min." Heart rate within the range of 60-100 beats per minute is generally considered normal for adults at rest. This value doesn't specifically indicate malnourishment.
Choice B rationale:
"Pink mucous membranes." Pink mucous membranes indicate adequate oxygenation and hydration but don't necessarily reflect nutritional status or malnourishment.
Choice C rationale:
"Pallor with scaly skin." Pallor (pale skin) along with scaly skin can be indicative of malnourishment. Malnourished individuals may not receive adequate n
Choice D rationale:
"Body mass index 23." A body mass index (BMI) of 23 falls within the normal range (18.5-24.9), so it doesn't necessarily indicate malnourishment. However, BMI alone may not fully capture malnourishment, as it doesn't consider other factors like muscle mass and specific nutrient deficiencies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["13.6"]
Explanation
The correct answer is 13.6 kg.
To convert pounds to kilograms, the formula is weight in pounds divided by 2.2. Given the child's weight is 30 lb, the calculation would be 30 / 2.2 ≈ 13.64 kg. Rounding to the nearest tenth gives us 13.6 kg.
Correct Answer is D
Explanation
The correct answer is choiced. "Describe your concerns about sleeping to me.".
Choice A rationale:
While offering frequent checks can provide some reassurance, it does not address the underlying fear the client is experiencing. It is more of a practical solution rather than a therapeutic one.
Choice B rationale:
Agreeing with the client’s fear without offering a solution or support can increase their anxiety. It is important to acknowledge their feelings but also to provide comfort and reassurance.
Choice C rationale:
Offering sleeping medication might help the client fall asleep, but it does not address the root cause of their fear. It is important to understand and address the client’s concerns directly.
Choice D rationale:
Asking the client to describe their concerns is a therapeutic approach that encourages them to express their fears.This allows the nurse to understand the client’s perspective and provide appropriate emotional support.
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