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?
Overweight.
Obesity class 1.
Underweight.
Healthy weight.
The Correct Answer is C
Choice A rationale:
Overweight is not applicable in this situation as the client's BMI indicates a weight status below the normal range.
Choice B rationale:
Obesity class 1 is not applicable in this situation as the client's BMI indicates a weight status below the normal range.
Choice C rationale:
Underweight is the correct choice. A BMI of less than 18.5 is considered underweight according to the World Health Organization (WHO) classification. A BMI of 17.2 falls below this threshold, indicating that the client is underweight. This is a cause for concern, as individuals with Crohn's disease often struggle with maintaining a healthy weight due to malabsorption issues and reduced appetite.
Choice D rationale:
Healthy weight is not applicable in this situation as the client's BMI is below the normal range, indicating an underweight status.
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Explanation
The client is at highest risk for developing mastitis evidenced by the client's visible cracknoted on left nipple
Correct Answer is C
Explanation
A. Incorrect. Placing a towel roll under the client's neck is a preventive measure to maintain proper cervical alignment, but it does not specifically address contracture prevention.
B. Incorrect. This can promote flexion of the knees, which may actually contribute to knee flexion contractures over time. While it might be comfortable for the client, it's not a preventive measure against contractures.
C. Correct. Orthotics can help maintain proper alignment of the foot and ankle, preventing foot drop and other related contractures. They are designed to support joints and muscles, minimizing the risk of stiffness and contracture formation.
D. Incorrect. Aligning a trochanter wedge between the client's legs might help prevent external rotation of the hips but does not specifically address contracture prevention.
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