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

Choice A Reason:
Performing passive range of motion and compare the findings is inappropriate. While assessing passive range of motion can provide information about joint mobility and flexibility, it may not directly address the asymmetry observed in the legs. Range of motion assessment is more relevant for evaluating joint function and flexibility rather than leg length asymmetry.
Choice B Reason:
Comparing measured circumferences of each extremity joint is inappropriate. Measuring circumferences of extremity joints may help identify differences in muscle mass or swelling, but it may not directly address the asymmetrical leg length observed. Circumference measurements are more relevant for assessing muscle bulk or detecting signs of edema rather than leg length asymmetry.
Choice C Reason:
Instructing client to walk across the room and observe the gait is inappropriate. Observing the client's gait can provide valuable information about their walking pattern and any abnormalities in movement. While an abnormal gait may be associated with leg length asymmetry, directly measuring leg length would provide more precise data for evaluation.
Choice D Reason:
Measuring the length of each leg and document the findings is appropriate. Measuring the length of each leg can help identify any significant differences in leg length, which could be contributing to the asymmetry observed. Leg length discrepancy can result from various musculoskeletal conditions such as scoliosis, hip dysplasia, or unequal growth rates. Documenting the findings allows for accurate tracking of changes over time and provides important information for healthcare providers to determine appropriate interventions, such as orthotic devices or physical therapy.

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.