A nurse is performing a nutritional screening for a client. Which of the following statements by the client indicates the need for further data collection?

"I eat at least two meals every day and snack frequently."

"I drink 4 ounces of wine with dinner several times each week."

"I take several prescription medications every day."

"I am able to keep my weight steady without gaining or losing."

Answer and Explanation

The Correct Answer is C

A. "I eat at least two meals every day and snack frequently.": Consuming at least two meals daily with additional snacks suggests a relatively consistent caloric intake. While a full dietary recall would still be appropriate, this statement alone does not immediately suggest nutritional risk without evidence of poor food quality or imbalance.

B. "I drink 4 ounces of wine with dinner several times each week.": Moderate alcohol intake, such as 4 ounces of wine with dinner, may not independently indicate nutritional compromise. Although excessive alcohol can interfere with nutrient absorption and metabolism, this amount does not automatically suggest malnutrition without additional risk factors.

C. "I take several prescription medications every day.": Multiple prescription medications raise concern for potential drug–nutrient interactions, altered appetite, gastrointestinal side effects, or impaired absorption of vitamins and minerals. Polypharmacy can also affect taste, swallowing, or metabolic processes, increasing the risk of nutritional deficiencies.

D. "I am able to keep my weight steady without gaining or losing.": Stable weight over time generally suggests adequate caloric intake relative to metabolic needs. Although body composition and diet quality still require evaluation, maintaining weight does not immediately signal nutritional risk in the absence of other concerning findings.

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Correct Answer is D

Explanation

A. Sinus tachycardia rate 104/min: Mild sinus tachycardia may occur in response to pain, anxiety, or hypovolemia and is usually not immediately life-threatening. While it should be monitored, it does not require urgent reporting unless it worsens or is accompanied by other concerning signs.

B. Two premature ventricular contractions per minute: Occasional PVCs can be benign, especially in a post-MI patient, and may not require immediate intervention. Frequent or paired PVCs, or those occurring in runs, are more concerning for ventricular arrhythmias.

C. First degree heart block: This is characterized by a prolonged PR interval but generally does not compromise cardiac output. It is often stable and can be monitored rather than reported as an urgent finding.

D. A new onset of atrial fibrillation: New-onset atrial fibrillation following a myocardial infarction increases the risk of decreased cardiac output, thromboembolism, and hemodynamic instability. This arrhythmia requires immediate notification of the provider for assessment and initiation of appropriate interventions such as rate or rhythm control and anticoagulation.

A. Sickle-cell anemia B. Herpes zoster C. Community-acquired pneumonia D. Viral meningitis

Correct Answer is A

Explanation

A. Sickle-cell anemia: Clients with sickle-cell anemia who are not actively infected do not pose an infectious risk, making them suitable roommates for an immunocompromised client receiving chemotherapy. Cohorting noninfectious clients together minimizes exposure to pathogens while allowing safe shared accommodations.

B. Herpes zoster: Active shingles (herpes zoster) is contagious, particularly to immunocompromised individuals. Sharing a room would place the client with Hodgkin’s disease at high risk for contracting a serious infection, which could lead to severe complications.

C. Community-acquired pneumonia: Pneumonia can be caused by bacteria or viruses and is transmissible through respiratory droplets. Placing an immunocompromised client with a person who has pneumonia increases the risk of infection, so it is not appropriate for room sharing.

D. Viral meningitis: Viral meningitis is contagious, and an immunocompromised client is highly susceptible to infection. Cohorting with a client who has viral meningitis would put the client with Hodgkin’s disease at significant risk for acquiring the illness.

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A nurse is performing a nutritional screening for a client. Which of the following statements by the client indicates the need for further data collection?

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