The nurse is assessing a 76-year-old client who has presented with an unintended weight loss of 10 lb over the past 8 weeks.
During the assessment, the nurse learns that the client has ill-fitting dentures and a limited intake of high-fiber foods.
What other health problem is the client at risk to develop?
Infection.
Deficient fluid volume.
Excessive intake of convenience foods.
Constipation.
The Correct Answer is D
Choice A rationale
Infection is not directly related to weight loss, ill-fitting dentures, or limited fiber intake. The primary risks are more connected to gastrointestinal function rather than infections. While malnutrition can affect immune response, infection risk isn’t the primary concern here.
Choice B rationale
Deficient fluid volume is not a direct consequence of weight loss or dietary habits related to ill-fitting dentures. While fluid intake should be monitored, it is not the most immediate risk associated with these symptoms.
Choice C rationale
Excessive intake of convenience foods might contribute to poor nutritional status and unintended weight loss, but it is not the primary risk. The client's condition more directly influences gastrointestinal health rather than dietary habits.
Choice D rationale
Constipation is a significant risk due to limited intake of high-fiber foods. Fiber is crucial for promoting bowel movements and preventing constipation. Weight loss and ill-fitting dentures may further reduce the client's dietary fiber intake, increasing the likelihood of constipation
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Cranial nerve VII (Facial nerve) controls muscles of facial expression and functions in taste sensations from the anterior two-thirds of the tongue, not balance.
Choice B rationale
Cranial nerve VI (Abducens nerve) controls lateral eye movement and has no role in balance or proprioception.
Choice C rationale
Cranial nerve VIII (Vestibulocochlear nerve) is responsible for hearing and balance. A positive Romberg test indicates issues with proprioception or vestibular function, which is directly linked to this nerve.
Choice D rationale
Cranial nerve IX (Glossopharyngeal nerve) involves taste sensation from the posterior third of the tongue and some swallowing functions, not balance.
Correct Answer is A
Explanation
Choice A rationale
A CPP of 40 mm Hg is considered low and indicates inadequate cerebral perfusion pressure, which requires immediate medical intervention.
Choice B rationale
A low CPP indicates compromised cerebral blood flow, leading to potential brain ischemia and damage.
Choice C rationale
A reading of 40 mm Hg is not inaccurate if it reflects the actual CPP of the client.
Choice D rationale
A CPP of 40 mm Hg is not high; it is low and requires prompt attention. .
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