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?

The correct answer is choice A. Ego integrity vs. despair.

Choice A rationale:

Erikson's Theory of Psychosocial Development outlines various stages of development that individuals go through across their lifespan. In the final stage, which occurs in late adulthood, individuals either experience a sense of ego integrity or despair. Ego integrity is characterized by a sense of fulfillment and satisfaction with one's life choices, while despair is marked by feelings of regret and a sense of unfulfillment. The older adult client expressing that their life has no purpose suggests a struggle with finding meaning and satisfaction, aligning with the ego integrity vs. despair stage.

Choice B rationale:

Generativity vs. self-absorption is a stage that occurs during middle adulthood. It involves concerns about contributing to society and the next generation. This stage is not applicable to the scenario described with an older adult who is grappling with a lack of purpose in life.

Choice C rationale:

Identity vs. role confusion is a stage that occurs during adolescence, where individuals explore their sense of self and develop their identities. This stage is not relevant to the older adult client's situation of feeling purposeless.

Choice D rationale:

Intimacy vs. isolation is a stage that typically occurs during young adulthood, where individuals seek close and meaningful relationships with others. This stage is not appropriate for the older adult's feelings of lacking purpose.

The correct answer is choice A. Perform a bladder scan.

Choice A rationale:

Performing a bladder scan is the first action the nurse should take before proceeding with intermittent urinary catheterization. A bladder scan assesses the bladder's volume and determines if catheterization is necessary. It helps avoid unnecessary catheterizations, reduces the risk of infection, and promotes patient comfort.

Choice B rationale:

While cleansing the meatus and providing perineal care are important steps in preparing for urinary catheterization, they come after assessing the need for catheterization. Without knowing the bladder volume, these actions could be premature.

Choice C rationale:

Providing perineal care is important for maintaining hygiene and preventing infection, but it should be done after the decision for catheterization has been made based on the bladder scan results.

Choice D rationale:

Lubricating the catheter is a step that should be taken after the decision for catheterization is made and the need for catheterization is confirmed. It helps ease the insertion process and reduce discomfort for the patient.