A nurse in a provider's office is caring for a client.
Click to highlight the findings that indicate malnutrition. To deselect a finding, click on the finding again.
Nurses' Notes
Today.
Client presents to the office with their adult daughter. Daughter states the client's forgetfulness has increased. She states. "I often notice uneaten meals in the microwave when I come over to visit." Daughter also reports that the client fell 1 month ago and has a wound on their leg that won't heal. On assessment skin is rough and dry, lungs are clear bilaterally, abdomen is soft and concave, and edema noted to the face and lower extremities.
Vital Signs
Today
- Temperature 37.7° C (98.9° F)
- Heart rate 103/min
- Respiratory rate 16/min
- Blood pressure 102/68 mm Hg
- Weight 65.9 kg (145 lb)
uneaten meals
wound on their leg that won't heal
skin is rough and dry
edema noted to the face and lower extremities
Weight 65.9 kg (145 lb)
The Correct Answer is ["A","B","C","D"]
- Uneaten meals suggest that the client is not consuming the food provided, which can lead to inadequate intake of nutrients and calories, thus indicating possible malnutrition.
- A wound that won't heal can be a sign of malnutrition, as proper nutrition is essential for wound healing and maintenance of skin integrity.
- Rough and dry skin can be indicative of malnutrition, particularly if there is a deficiency in essential fatty acids and other nutrients that maintain skin health.
- Edema to the face and lower extremities can be a sign of protein-energy malnutrition, where the body does not get enough protein to maintain plasma oncotic pressure, leading to fluid accumulation in tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Raw celery and tomatoes are not recommended in the early postoperative period following gastric bypass surgery due to their high fiber content, which may be difficult to tolerate.
B. Drinking at least 100 ounces of fluids per day may be excessive and can increase the risk of complications such as dumping syndrome in the early postoperative period following gastric bypass surgery. Fluid intake should be carefully monitored and follow the healthcare provider's recommendations.
C. Consuming liquids or pureed foods in the early postoperative period following gastric bypass surgery allows the gastrointestinal tract time to heal and adjust to the changes from the surgery. This statement indicates an understanding of the appropriate dietary progression after surgery.
D. The amount of protein intake may vary depending on individual factors and should be guided by the healthcare provider's recommendations. However, focusing solely on protein intake does not address the need for a gradual dietary progression in the early postoperative period.
Correct Answer is D
Explanation
A. Lactulose is a laxative that works by reducing the absorption of ammonia in the colon, leading to increased bowel movements. Therefore, there should be an increase rather than a decrease in the number of bowel movements with this medication.
B. Lactulose is typically administered orally or rectally, not intravenously.
C. Lactulose does not treat infection; it helps reduce ammonia levels in hepatic encephalopathy by promoting bowel movements to expel ammonia.
D. Monitoring the serum ammonia level is essential in assessing the effectiveness of lactulose therapy. Reduction in serum ammonia levels indicates that the medication is working to reduce ammonia absorption in the colon.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today