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 D
Explanation
The correct answer is choice d. Actual loss.
Choice A rationale: Complicated grief refers to an intense and prolonged period of mourning that interferes with daily life. It is not typically associated with the immediate postoperative period following a mastectomy.
Choice B rationale: Maturational loss is related to the normal life transitions and developmental changes, such as children leaving home or retirement. It does not apply to the loss experienced after a mastectomy.
Choice C rationale: Disenfranchised grief occurs when a person’s grief is not socially recognized or supported, such as the loss of a pet or an ex-spouse. While the grief after a mastectomy can be profound, it is generally acknowledged and supported by healthcare providers and society.
Choice D rationale: Actual loss refers to the tangible loss of a person, object, or body part. In this case, the client is experiencing the loss of a breast, which is a significant and visible change to their body. This type of loss can deeply affect a person’s self-image and emotional well-being.
Correct Answer is D
Explanation
The correct answer is choice D: Choose a private room for the interview.
Choice D rationale:
Opting for a private room for the interview is essential when interacting with a client who uses a hearing aid. This choice helps minimize background noise and distractions, ensuring effective communication between the nurse and the client. Adequate lighting and minimizing auditory interference are crucial for clients with hearing difficulties.
Choice A rationale:
Sitting beside the client is a considerate approach, but it may not directly address the hearing aid user's needs. The focus should be on creating an optimal environment for communication, which includes minimizing auditory and visual obstacles.
Choice B rationale:
Speaking slowly and loudly to the client is not the most appropriate approach. While speaking clearly and facing the client is recommended, speaking loudly may distort sounds and hinder understanding for clients with hearing aids.
Choice C rationale:
Dimming the lights in the client's room is not necessary for addressing the needs of a client with a hearing aid. Adequate lighting is important for lip-reading and effective communication, especially for clients who rely on visual cues.
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