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 B

Explanation

a. a client communicates significant distress. While significant distress is important to consider, it alone does not necessarily indicate a risk for developing mental illness unless it also impacts daily functioning and coping mechanisms.
b. maladaptive responses to stress are coupled with interference in daily functioning. This choice is correct because it reflects a combination of maladaptive coping (which can exacerbate mental health issues) and interference with daily functioning (a key indicator of mental illness according to DSM-5 criteria).
c. thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. While alignment with DSM-5 criteria is crucial for diagnosis, this choice alone does not address the risk aspect. The focus should be on behaviors that lead to impairment in daily functioning and coping.
d. a client uses defense mechanisms as ego protection. Using defense mechanisms is a normal part of human behavior and not necessarily indicative of mental illness risk unless these mechanisms are maladaptive and interfere with functioning.

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

At what point should the nurse determine that a client is at risk for developing mental illness? When:

Correct Answer is B

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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