In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care?

Reference Range:

Underweight: BMI is less than 18.5; Normal weight: BMI is 18.5 to 24.9; Overweight: BMI is 25 to 29.9; Obese: BMI is 30 or more

Fluid volume excess.

Unbalanced nutrition, less than body needs.

Unbalanced nutrition, greater than body needs.

Fluid volume deficit.

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Fluid volume excess is incorrect. Fluid volume excess refers to an overabundance of fluid in the body, leading to symptoms such as edema, weight gain, and hypertension. However, a BMI of 14 kg/m^2 indicates underweight, not fluid volume excess. Therefore, this choice is incorrect.
Choice B Reason:
Unbalanced nutrition, less than body needs is correct. A BMI of less than 18.5 indicates underweight according to the provided reference range. Underweight individuals often do not consume enough nutrients to meet their body's needs, leading to potential nutritional deficiencies. Therefore, the nursing problem of "Unbalanced nutrition, less than body needs" is appropriate for addressing the client's low BMI.
Choice C Reason:
Unbalanced nutrition, greater than body needs is incorrect. This choice would be more applicable if the client's BMI indicated overweight or obesity, as it suggests an excess intake of nutrients relative to the body's needs. However, a BMI of 14 kg/m^2 indicates underweight, not excess weight. Therefore, this choice is incorrect.
Choice D Reason:
Fluid volume deficit is incorrect. Fluid volume deficit refers to a decreased amount of fluid in the body, leading to symptoms such as dehydration, decreased urine output, and hypotension. However, a low BMI does not necessarily indicate fluid volume deficit; it primarily reflects undernutrition. Therefore, this choice is incorrect.

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Correct Answer is D

Explanation

Choice A Reason:
Hyperactive bowel sounds are incorrect. Hyperactive bowel sounds refer to increased or loud gurgling noises heard during auscultation of the abdomen, which may indicate increased intestinal motility or bowel obstruction. These sounds are typically high-pitched and occur in various abdominal quadrants, rather than specifically in the upper midline area.
Choice B Reason:
A minor variation is incorrect. A minor variation in abdominal sounds may occur and could be considered normal. However, a low-pitched blowing sound in the upper midline area is not typically categorized as a minor variation but rather as an abnormal finding that warrants further investigation.
Choice C Reason:
Normal borborygmic sounds is incorrect. Borborygmic refers to the normal rumbling or gurgling sounds produced by the movement of gas and fluid in the intestines. While borborygmic sounds may be heard during abdominal auscultation, they are typically described as high-pitched and occur in various abdominal quadrants, not specifically in the upper midline area. Therefore, they are not likely to be the indication of the finding described in the scenario.
Choice D Reason:
Possible renal artery stenosis is correct. Renal artery stenosis is a condition characterized by the narrowing of one or both renal arteries, which can lead to reduced blood flow to the kidneys. When auscultating the abdomen, a low-pitched blowing sound (bruit) heard over the upper midline area could indicate turbulence of blood flow in the renal arteries. This bruit is typically associated with renal artery stenosis and reflects the increased velocity of blood passing through a narrowed arterial lumen. Identifying a renal artery bruit during abdominal auscultation warrants further investigation, such as imaging studies or referral to a specialist for evaluation and management of renal artery stenosis.

A. Give the client an object to hold. B. Instruct the client to close his eyes. C. Apply resistance to the client's arms. D. Palpate the client's muscle tone.

Correct Answer is C

Explanation

Choice A Reason:
Giving the client an object to hold is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While providing an object to hold may engage the muscles, it does not specifically target the muscles involved in arm flexion, which are primarily the biceps brachii and brachialis muscles. Therefore, it may not accurately assess muscle strength during arm flexion.
Choice B Reason:
Instructing the client to close his eyes is not the most appropriate action before asking the client to flex his arms to assess muscle strength. Instructing the client to close his eyes primarily tests proprioception and balance rather than muscle strength. While proprioception is an important aspect of overall neurological function, it is not directly related to assessing muscle strength during arm flexion.
Choice C Reason:
Applying resistance to the client's arms is the most appropriate action before asking the client to flex his arms to assess muscle strength. Applying resistance to the client's arms during flexion allows the nurse to evaluate the client's ability to generate force against resistance, providing a more accurate assessment of muscle strength in the biceps brachii and brachialis muscles.
Choice D Reason:
Palpating the client's muscle tone is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While palpating muscle tone is important for assessing muscle integrity, it does not directly evaluate muscle strength during arm flexion. Muscle tone refers to the resting tension in a muscle and may not accurately reflect muscle strength during active movement.

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Naxlex Comprehensive Predictor Exams

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

Correct Answer is D

Explanation

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

Correct Answer is C

Explanation

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