A nurse is collecting data from a client who is malnourished due to inflammatory bowel disease. Which of the following findings should the nurse expect?
Brittle hair
Yellow conjunctivae
Bradycardia
Clubbing of the fingernails
The Correct Answer is A
A. Brittle hair: Malnutrition often leads to protein and micronutrient deficiencies, which impair hair growth and texture, resulting in dry, brittle, or thinning hair. This is a common visible sign in clients with poor nutritional status.
B. Yellow conjunctivae: Yellowing of the conjunctivae typically indicates jaundice due to liver dysfunction or hemolysis, not malnutrition from inflammatory bowel disease. It reflects bilirubin accumulation rather than nutrient deficiency.
C. Bradycardia: While bradycardia may occur in severe starvation or electrolyte imbalance, it is not a consistent or early indicator of malnutrition from inflammatory bowel disease. It requires further context to be clinically relevant.
D. Clubbing of the fingernails: Clubbing is associated with chronic hypoxia or pulmonary/cardiac conditions. It is not commonly linked to malnutrition or inflammatory bowel disease unless there are severe complications such as chronic anemia or hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Scrubs hands with antibacterial soap for 10 seconds: The recommended duration for effective handwashing is at least 20 seconds to ensure adequate removal of microbes and reduce infection risk. Washing for only 10 seconds is insufficient to properly cleanse the hands.
B. Washes his hands under hot running water: Using hot water can cause skin irritation and dryness, which may lead to compromised skin integrity. Warm or cold water is recommended as it effectively removes germs without damaging the skin.
C. Uses firm, circular motions to wash his hands: Using firm, circular motions ensures thorough cleansing of all hand surfaces, including between fingers and around nails. This technique promotes effective removal of dirt and microorganisms and is consistent with hand hygiene best practices.
D. Dries his hands from the forearms to the fingers: Drying should always proceed from the fingertips toward the forearms to prevent recontamination of clean hands. Drying from forearms to fingers can transfer contaminants back to the hands, defeating the purpose of handwashing.
Correct Answer is B
Explanation
A. Goggles: Goggles protect the eyes from splashes and should be removed after gloves and gown, once the risk of contamination is lower. Removing them too early can increase the risk of contamination if hands are still contaminated.
B. Gloves: Gloves are the most contaminated item after wound care and should be removed first to prevent spreading microorganisms to other personal protective equipment or the nurse’s skin. Proper glove removal technique reduces the risk of self-contamination.
C. Mask: Masks protect the respiratory tract and are typically removed last, after gloves, gown, and goggles, to maintain protection as long as possible. Removing the mask too early can expose the nurse to airborne particles.
D. Gown: The gown is removed after gloves because it is also contaminated but less so than gloves. Removing gloves first minimizes transferring contaminants from the gloves to the gown or other surfaces during removal.
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