The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?
Body mass index (BMI) of 17.
Decrease in the appetite.
Dry mucosal membranes.
Weight of 227 pounds (103 kg).
The Correct Answer is A
Choice A
Body mass index (BMI) of 17 is the correct finding. A low Body Mass Index (BMI) is a common indicator of malnutrition. BMI is a measurement that considers a person's weight in relation to their height. A BMI of 17 suggests that the person is underweight, which can be indicative of malnutrition. Malnutrition is characterized by inadequate intake of calories, protein, vitamins, and minerals that are essential for maintaining health and well-being.
Choice B
Decrease in appetite is not correct finding. While a decrease in appetite might contribute to malnutrition, it's a symptom rather than a definitive indicator.
Choice C
Dry mucosal membranes are not the correct finding. Dry mucosal membranes can be related to dehydration or other conditions, but they are not specific enough to confirm malnutrition on their own.
Choice D
Weight of 227 pounds (103 kg) is not the correct finding. This weight is not necessarily indicative of malnutrition on its own. It's important to consider the individual's height, BMI, and other factors when assessing malnutrition.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A
Low residue diet is incorrect. A low residue diet is typically recommended for individuals with gastrointestinal conditions like inflammatory bowel disease or diverticulitis. This diet limits high-fibre foods to reduce bowel movements and ease digestive stress. However, it might not be the best option for a client with stomatitis who is struggling to eat due to mouth pain.
Choice B
While soft,it doesn't specifically prioritize the high protein content necessary for someone who has lost a quarter of their body weight.
Choice C
While easy to swallow, a regularpureed diet may still include acidic or spicy foods (like citrus or pepper) that would be excruciating for a client with stomatitis.
Choice D
A weight loss of 25% is critical and indicates a state of severe catabolism (muscle wasting). The client requires high protein and high calories to promote tissue repair and counteract the effects of chemotherapy. Stomatitis causes painful open sores in the mouth. A soft diet consists of foods that are easy to chew and swallow, minimizing mechanical trauma to the sensitive mucous membranes.

Correct Answer is D
Explanation
Correct answer: D
Choice A
Urinary ketones are not most important. Monitoring urinary ketones can provide information about the utilization of glucose and fat as energy sources. However, it is not the primary lab value to monitor in TPN administration.
Choice B
Serum protein is not most important. Monitoring serum protein levels is important to assess nutritional status, but it might not be as immediate a concern as serum osmolarity.
Choice C
Serum osmolarity reflects the concentration of particles (such as electrolytes, glucose, and other solutes) in the blood. Monitoring serum osmolarity is importantto prevent complications related to fluid and electrolyte imbalances that can arise from the administration of TPN.Blood glucose levels (option D) are more critical because TPN can significantly impact glucose metabolism
Choice D
When caring for a client receiving total parenteral nutrition (TPN), the nurse’spriorityis tomonitor blood glucose levels. TPN can affect blood glucose, and observing for signs of hyperglycemia or hypoglycemia is crucial.Additionally, administering insulin as directed based on blood glucose levels is essential.

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