A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

Healthy weight

Overweight

Underweight

Obesity class 1

Answer and Explanation

The Correct Answer is C

A. Healthy weight – A BMI between 18.5 and 24.9 is classified as healthy. Since the client's BMI is 17.2, they do not fall within this range.

B. Overweight – Overweight is defined as a BMI between 25.0 and 29.9. The client's BMI of 17.2 is far below this range.

C. Underweight – A BMI below 18.5 is classified as underweight. Since the client's BMI is 17.2, they fall into this category. Clients with Crohn’s disease often experience malabsorption and weight loss, leading to a low BMI.

D. Obesity class 1 – Obesity is categorized as a BMI of 30.0 or higher. The client’s BMI is far below this classification.

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Correct Answer is D

Explanation

A. A client who had a right hemisphere stroke – While a stroke may cause weakness on one side, BP measurements can still be taken unless there are additional contraindications like lymphedema or a fistula.

B. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm – BP should never be taken on the arm with an AV shunt, but this does not mean the right arm is unavailable.

C. A client who had blood drawn from the right antecubital area 1 hr ago – Blood draws do not typically affect BP measurements significantly unless there is excessive bruising or infiltration.

D. A client who has a right peripherally inserted central catheter (PICC) – Correct. Blood pressure cuffs can cause compression on the PICC line, leading to catheter occlusion, displacement, or thrombosis. The nurse should instruct the AP to use the opposite arm.

A. Place the client in Trendelenburg position. B. Reinsert the protruding intestinal tissue. C. Cover the wound with a saline-soaked dressing. D. Monitor vital signs every 30 min.

Correct Answer is C

Explanation

A. Placing the client in Trendelenburg position is incorrect because this position does not reduce tension on the abdominal wound and may increase intra-abdominal pressure.

B. Reinserting the protruding intestinal tissue is incorrect because this can introduce infection and cause further damage.

C. This is the correct answer. The priority action is to cover the wound with a sterile, saline-moistened dressing to prevent tissue drying and reduce infection risk.

D. Monitoring vital signs is important, but the priority is to protect the exposed abdominal contents.

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A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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