The nurse is assessing an alert and independent older client for the risk of malnutrition. What item is most appropriate to assess?

"Where do you buy your food?"

"Does someone else prepare your meals?"

"Tell me what you eat in a typical day.

Are you taking any medications that change your taste of foods?"

Answer and Explanation

The Correct Answer is C

a. "Where do you buy your food?" While this provides information about food access, it doesn’t directly assess nutritional intake.
b. "Does someone else prepare your meals?" This might provide insight into the client's independence, but it doesn't directly assess nutritional intake.
c. "Tell me what you eat in a typical day." This directly assesses the client’s dietary intake and provides a comprehensive view of their nutrition status.
d. "Are you taking any medications that change your taste of foods?" This is relevant but more specific to one aspect of dietary intake. It does not provide a full picture of the client’s nutritional status like option c.

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Correct Answer is A

Explanation

a. "Focus on the feelings generated by the hallucinations and present reality." This approach validates the child's experience and feelings while gently orienting them to reality, which is a therapeutic communication technique.
b. "Ignore what they are saying, while attempting to discover the underlying cause." Ignoring the child’s statements can make them feel dismissed and could increase their distress. It is important to address their experience directly and compassionately.
c. "Present objective evidence that the voices are not real." Presenting objective evidence may not be effective as the child’s belief in the voices can be very strong, and this approach may lead to further agitation.
d. "Tell them to stop discussing the voices." This approach is dismissive and does not help the child manage their symptoms or feel understood. It is important to engage with the child’s experience constructively.

A. Blood pressure 110/70 B. heart rate 86 C. Hypoactive bowel sounds D. Increased restlessness E. Negative Homan's sign

Correct Answer is ["D"]

Explanation

a. Blood pressure 110/70: This is within normal range for many individuals and is not immediately concerning in the post-operative context.
b. heart rate 86: This is a normal heart rate for most individuals and is not concerning post-operatively.
c. Hypoactive bowel sounds: Hypoactive bowel sounds are common post-operatively due to anesthesia and are not immediately concerning.
d. Increased restlessness Increased restlessness can be a sign of pain, anxiety, hypoxia, or other complications and should be addressed promptly.
e. Negative Homan's sign: A negative Homan’s sign indicates no apparent deep vein thrombosis and is a positive finding.

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The nurse is assessing an alert and independent older client for the risk of malnutrition. What item is most appropriate to assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia disorder, tells them that voices command the child to harm others. Which is the appropriate nursing response?

Correct Answer is A

Explanation

The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

Correct Answer is ["D"]

Explanation

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