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 C
Explanation
Choice A
"The bruises on my arms are all gone." This statement is incorrect. Bruising can be influenced by various factors, including platelet levels and clotting factors, but it is not a specific sign of Vitamin A deficiency.
Choice B
"My feet don't tingle like they used to. “This statement is incorrect. Tingling feet might be related to nerve function or circulation, but it is not a direct symptom of Vitamin A deficiency.
Choice C
"I can see at night when I wake up now. “This statement is correct. Vitamin A is essential for maintaining good vision, especially in low-light conditions. Deficiency of Vitamin A can lead to a condition called night blindness, where individuals have difficulty seeing in low light. Therefore, the statement "I can see at night when I wake up now" (option C) indicates that an adequate amount of Vitamin A is being provided.
Choice D
"My tummy seems so much smaller now. “This statement is incorrect. Changes in tummy size are not typically related to Vitamin A deficiency. Vitamin A deficiency is more closely associated with symptoms related to vision and immune function.
Correct Answer is D
Explanation
Choice A
This is unnecessary and not a standard clinical practice for confirming NGT placement.
Choice B
Withdrawing the NGT and reinsert should not be implemented. If the NGT is in the wrong place, reinserting it without further assessment could worsen the situation. The nurse should not reinsert the NGT until the correct placement is confirmed.
Choice C
Connecting the NGT to wall suction should not be implemented. Connecting the NGT to wall suction without verifying its placement could cause harm, especially if the tube is in the respiratory tract.
Choice D
This is the most evidence-based bedside method to confirm placement after the initial X-ray. Gastric aspirate typically has a pH of 5.0 or less. If the pH is higher (e.g., >6.0), it may indicate that the tube is in the lungs or the small intestine.
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