Which nutritional data obtained from a client needs MOST validation by a nurse?

"I do not eat salty foods and snacks

"My rings are not fitting on my fingers like they usually do"

"I exercise about 20 minutes a day by walking"

"High blood pressure is present in my mother & grandmother"

Answer and Explanation

The Correct Answer is B

A) "I do not eat salty foods and snacks": This statement indicates the client's dietary habits and, while it can impact overall health, it does not necessarily require immediate validation unless there is reason to doubt its accuracy or it is related to a specific health concern being addressed.

B) "My rings are not fitting on my fingers like they usually do": This statement suggests a change in the client's physical condition, likely indicating fluid retention or edema. This symptom requires validation as it could signify an underlying issue such as heart failure, kidney problems, or other medical conditions that need prompt attention.

C) "I exercise about 20 minutes a day by walking": This statement reflects the client's physical activity routine. While it's important for assessing overall health and fitness, it does not demand immediate validation unless related to a specific health issue.

D) "High blood pressure is present in my mother & grandmother": This statement provides valuable family history information, which is important for assessing genetic risk factors. However, it does not require urgent validation compared to physical changes indicating potential health problems.

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Correct Answer is A

Explanation

(a) Liver Disease:

Pitting edema is commonly seen in liver disease, especially in conditions like cirrhosis. Liver disease can lead to hypoalbuminemia, where low levels of albumin in the blood cause fluid to leak into the interstitial spaces, resulting in edema. Additionally, liver disease often leads to portal hypertension, which can also contribute to the development of edema.

(b) Diabetes mellitus:

While diabetes can cause complications such as diabetic nephropathy, which may lead to fluid retention, pitting edema is not a primary symptom directly associated with diabetes mellitus. Diabetic patients may develop edema due to kidney issues, but it is not as directly associated as with liver disease.

End-stage renal disease (ESRD) can indeed cause significant fluid retention and edema, including pitting edema. The kidneys' inability to excrete excess fluid leads to its accumulation in tissues. However, the question seems to point towards liver disease, which directly leads to conditions causing pitting edema.

(d) Colon Cancer:

Colon cancer is not typically associated with pitting edema. While advanced cancer can lead to various complications, including fluid imbalances, it is not a primary cause of pitting edema. Edema related to cancer is often more localized and associated with tumor sites or treatment areas.

A. Soles of the feet B. Oral mucosa C. Ear lobes D. Conjunctivae

Correct Answer is B

Explanation

(a) Soles of the feet:

The soles of the feet are not considered the most reliable indicator of central cyanosis because peripheral areas can be affected by various factors, including temperature and circulation. Changes in color here might not accurately reflect central oxygenation status.

(b) Oral mucosa:

The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygenation status of the central circulatory system. Cyanosis in this area indicates a significant drop in arterial oxygen saturation and is a more direct indicator of hypoxemia compared to peripheral sites.

Ear lobes, like the soles of the feet, can be influenced by peripheral circulation and environmental factors. While cyanosis can be observed here, it is not as reliable as central sites like the oral mucosa for assessing systemic oxygenation.

(d) Conjunctivae:

The conjunctivae can show signs of cyanosis, but the oral mucosa is still a more sensitive and reliable indicator for central cyanosis. The oral mucosa provides a clear and consistent site to assess oxygenation in emergency situations.

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Which nutritional data obtained from a client needs MOST validation by a nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In which disease process should a nurse expect to see a client with the presence of pitting edema?

Correct Answer is A

Explanation

While working in the Emergency department a Rapid response nurse is evaluating a patient in acute respiratory failure after a motor vehicle crash. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Correct Answer is B

Explanation

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