A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

Encourage the client to look at the balance beam

Have the client wear the same clothing every day.

Weigh the client at the same time in the morning

Use the same scale to weigh the client.

Discuss the client's weight with her after each measurement.

Answer and Explanation

Correct Answer : B,C,D

A) Encourage the client to look at the balance beam:

Encouraging the client to look at the balance beam may help her feel more engaged in the process of weight measurement. This can foster trust and cooperation during what may be a challenging procedure due to her history of Anorexia and Bulimia Nervosa.

B) Have the client wear the same clothing every day:

Consistency in clothing helps to minimize variations in weight measurements that could be attributed to changes in clothing weight rather than actual body weight fluctuations. This practice ensures more accurate and reliable serial weight measurements.

C) Weigh the client at the same time in the morning:

Weighing the client at the same time each day helps to standardize conditions and minimize daily variations due to factors like hydration levels and food intake, providing more accurate serial weight measurements.

D) Use the same scale to weigh the client:

Using the same scale ensures consistency in measurement accuracy. Different scales can yield slightly different readings, which could affect the interpretation of weight trends over time.

E) Discuss the client's weight with her after each measurement:

While discussing weight may be part of the client's care plan, it's not necessarily a standard action during the process of conducting serial weight measurements. The focus during the actual weighing process should be on maintaining consistency and accuracy.

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Correct Answer is A

Explanation

A) "Let's discuss your risk factors for heart disease.":

A waist circumference of 43 inches (109 cm) in a male is considered elevated and indicates central obesity, which is a significant risk factor for cardiovascular diseases, including heart disease, hypertension, and type 2 diabetes. Addressing this finding by discussing risk factors for heart disease is appropriate and necessary for preventive healthcare.

B) "We should review the amount of protein in your diet.":

While diet is important, protein intake is not directly related to waist circumference. The primary concern with a large waist circumference is the associated risk of metabolic and cardiovascular conditions, rather than specific macronutrient consumption.

C) "Waist circumference can vary over the course of the day.":

Though there can be minor variations in waist circumference throughout the day due to factors like fluid retention or meals, a measurement of 43 inches is significantly above the threshold indicating central obesity. This warrants a discussion about health risks rather than focusing on daily fluctuations.

D) "You probably have a vitamin deficiency.":

Vitamin deficiencies are not directly indicated by waist circumference measurements. This statement is not appropriate given the finding, as the primary concern with a large waist circumference is its association with increased risk of chronic diseases rather than nutrient deficiencies.

A. Mucous Membranes B. Dorsal surface of the hand C. Dorsal surface of the foot D. Pinnae of the ears

Correct Answer is A

Explanation

A. Mucous Membranes:

In clients with dark skin, mucous membranes such as the lips, tongue, and gums are the best sites to assess for cyanosis. These areas have less pigmentation and are more vascular, allowing for a more accurate evaluation of oxygenation and the presence of cyanosis.

B. Dorsal surface of the hand:

The dorsal surface of the hand can be used to assess for cyanosis in lighter-skinned individuals, but it is less reliable in dark-skinned clients due to the higher melanin content, which can obscure the bluish tint indicative of cyanosis.

C. Dorsal surface of the foot:

Similar to the dorsal surface of the hand, the dorsal surface of the foot is not an ideal site for assessing cyanosis in clients with dark skin. The presence of melanin can make it difficult to detect changes in skin color.

D. Pinnae of the ears:

The pinnae of the ears are also not the best sites for assessing cyanosis in dark-skinned clients. These areas can be highly pigmented, which can mask the bluish discoloration associated with cyanosis. The mucous membranes remain the most reliable site for this assessment.

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A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

Nursing Test Bank

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Correct Answer is A

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Correct Answer is A

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