The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status?

A 24 hour diet history.

Status of current appetite.

History of a recent weight loss.

Condition of hair, nails, and skin.

Answer and Explanation

The Correct Answer is D

A.   While a 24-hour diet history can provide valuable information about a person's dietary intake, it may not accurately reflect their long-term nutritional habits. Additionally, some individuals may underreport or overreport their food intake.
B.   A person's current appetite can be affected by various factors, including illness, medication, and emotional state. It may not be a reliable indicator of long-term nutritional status.
C.   While weight loss can be a sign of nutritional problems, it is not always indicative of a deficiency. Other factors, such as increased physical activity or illness, can also contribute to weight loss.
D.   The condition of hair, nails, and skin can provide valuable clues about a person's nutritional status.
For example, dry, brittle hair and nails, as well as pale or scaly skin, can be signs of nutrient deficiencies such as iron, vitamin B12, or protein deficiency. These visible signs can be more indicative of long-term nutritional deficiencies than other factors.

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Correct Answer is D

Explanation

A. This may involve using a stethoscope to auscultate the apical pulse, as it might be more easily heard than felt, especially in individuals with significant muscle mass or other anatomical variations. This approach ensures that a thorough cardiac assessment is conducted.
B. Dimming the lights would not impact the ability to palpate or auscultate the apical pulse. Lighting adjustments are generally more relevant for visual examinations rather than for palpation or auscultation of heart sounds. This action would not address the issue of locating the apical pulse.
C. While steroid use can affect cardiovascular health, such as potentially causing changes in heart size or function, questioning the client about steroid use is not the immediate priority if the apical pulse cannot be palpated. The priority should be to ensure a correct assessment and use proper techniques to locate the pulse.
D. Positioning the client in high Fowler's position (sitting up at a 60-90 degree angle) can help in various cardiac assessments and might make it easier to detect the apical pulse, especially if the client has a high muscle mass. This position can improve access to the chest and potentially facilitate better auscultation of heart sounds.

A. Complete a mental status exam. B. Obtain a blood alcohol level. C. Inspect legs for infection or trauma. D. Inquire about dietary salt intake.

Correct Answer is C

Explanation

A. The client’s current symptoms—pain, significant leg edema, and swelling—are more pressing and suggest a need to evaluate the physical cause of these symptoms rather than focusing immediately on mental status.
B. Obtaining a blood alcohol level might be relevant if there is a suspicion that recent alcohol use is contributing to the client’s condition or affecting his overall health. However, the primary concern in this case is the significant edema and pain in the left leg.
C. This is the most pertinent action to take first. The client’s symptoms of severe edema and pain in one leg, along with a history of CVA and alcohol abuse, raise concerns about possible causes such as deep vein thrombosis (DVT), infection, or trauma. Inspecting the legs for signs of infection or trauma (bruising, cuts) is crucial to determine the underlying cause of the symptoms and guide appropriate treatment.

D. While excessive salt intake can contribute to fluid retention and edema, the degree of swelling described (4+ pitting edema) and the localized nature of the problem in the left leg make it less likely that dietary salt alone is the cause.

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The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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