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 A
Explanation
A. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia, which can lead to symptoms such as increased thirst. Notifying the provider of increased thirst can help monitor for potential electrolyte imbalances.
B. Consuming foods high in potassium can exacerbate hyperkalemia, which is a potential side effect of spironolactone. Clients prescribed spironolactone are typically advised to avoid potassium-rich foods.
C. Using a salt substitute to season foods can increase sodium intake, which may counteract the effects of spironolactone and increase the risk of fluid retention and hypertension.
D. Taking spironolactone at bedtime is not typically recommended. It is usually taken in the morning to avoid disrupting sleep due to increased urination.
Correct Answer is C
Explanation
A. Legumes are plant-based sources of protein, but they are not considered complete proteins as they do not contain all essential amino acids in sufficient quantities.
B. Almonds are also a plant-based source of protein, but like legumes, they are not considered complete proteins.
C. Salmon is a complete protein because it contains all essential amino acids in sufficient quantities.
D. Gelatin is derived from collagen and is not a complete protein because it lacks certain essential amino acids.
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