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 C

Explanation

a. Loose associations involve a disorganized and fragmented way of thinking where the person’s thoughts are only loosely connected.
b. Dyslexia is a learning disorder characterized by difficulty reading.
c. A neologism is a newly coined word or expression that is often used by individuals with schizophrenia. It is a made-up word that has meaning only to the person using it.
d. Flight of ideas is a rapid shift from one topic to another, typically seen in manic episodes of bipolar disorder.

A. Altered thought processes; call an emergency treatment team meeting. B. Command hallucinations; warn the psychiatrist. C. Persecutory delusions; orient the client to reality. D. Magical thinking; administer an antipsychotic medication.

Correct Answer is B

Explanation

a. Altered thought processes; call an emergency treatment team meeting. While altered thought processes are present, the urgent concern is the command hallucination directing the client to harm the psychiatrist. An emergency treatment team meeting may not provide the immediate intervention required.
b. Command hallucinations; warn the psychiatrist. This is correct because the client is experiencing command hallucinations that pose a direct threat to the psychiatrist. The nurse has a duty to warn the potential victim and ensure the safety of both the client and others.
c. Persecutory delusions; orient the client to reality. Persecutory delusions are present, but the immediate danger from the command hallucinations takes precedence. Orienting the client to reality does not address the urgent safety issue.
d. Magical thinking; administer an antipsychotic medication. Magical thinking is not the correct symptom here. Administering medication is part of treatment but does not address the immediate safety concern.

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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?

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Naxlex Comprehensive Predictor Exams

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