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 C
Explanation
The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”
Choice A rationale:
Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.
Choice B rationale:
Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.
Choice C rationale:
Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.
Choice D rationale:
Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.
Correct Answer is D
Explanation
The correct answer is choice D: "Provide mouth care to them at least every 2 hours."
Choice A rationale:
Encouraging meals at least three times daily is not appropriate for a client who is near death. As clients approach the end of life, their appetite often decreases, and they may be unable to tolerate regular meals. It's more important to focus on providing comfort and relief.
Choice B rationale:
Keeping the room warm to help them breathe easier is not necessarily true. While a comfortable room temperature can be important for the client's overall comfort, warmth alone does not significantly impact breathing in the context of impending death. Breathing difficulties at this stage are usually related to physiological changes rather than room temperature.
Choice C rationale:
Helping the client onto their left side if they are experiencing nausea is not a universally applicable instruction. While left-side positioning can help alleviate nausea for some clients, it might not be suitable for everyone. Nausea can be caused by various factors, and the caregiver should assess the client's comfort and preferences before changing their position.
Choice D rationale:
Providing mouth care to the client at least every 2 hours is the most appropriate instruction among the choices. Near the end of life, many clients become less able to maintain their oral hygiene due to various factors, including weakness and reduced consciousness. This can lead to discomfort and potential complications. Regular mouth care helps keep the client's mouth moist and clean, enhancing their overall comfort.
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