A nurse in an emergency department is caring for a client.
Which of the following information provided by the client indicates improvement? Select all that apply.
“I have gained 1.8 kg (4 lb) recently, and my BMI is 18.9.”
“My adult child prepares two meals per day for me.”
“My clothing is always clean and appropriate for the weather.”
“I receive three baths per week from a home care aide.”
“I frequently have toothaches and haven’t had dental care in a while.”
“I make eye contact and smile while speaking.”
Correct Answer : A,B,E
The correct answer is choice a, b, e.
Choice A rationale: A recent weight gain of 1.8 kg (4 lb) with a BMI of 18.9 may indicate potential nutritional issues or underlying health problems that require further investigation.
Choice B rationale: Having an adult child prepare meals could suggest the client may have difficulties with meal preparation, possibly due to physical or cognitive limitations.
Choice C rationale: Clean and weather-appropriate clothing indicates the client is managing their personal hygiene and dressing appropriately, which does not typically prompt further assessment.
Choice D rationale: Receiving regular baths from a home care aide suggests the client has support for personal hygiene, which is generally a positive indicator and does not necessitate further assessment.
Choice E rationale: Frequent toothaches and lack of dental care can indicate poor oral health, which can have significant implications for overall health and nutrition, warranting a more detailed assessment.
Choice F rationale: Making eye contact and smiling while speaking generally indicates good social interaction skills and mental well-being, which does not typically prompt further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
the correct answer isd. Your desire to be an organ donor must be documented in writing.This is because organ donation is a legal and medical process that requires your consent and documentation1. Some of the other options are incorrect or misleading. Here are some explanations:
- a.Your namecanbe removed once you are listed on the organ donor list2.You can change your mind at any time and revoke your consent to donate
- b.Youdo nothave to be at least 21 years of age to become an organ donor2.Many states allow people younger than 18 to register as organ donors, but they need parental or guardian consent if they die before their 18th birthday
- c.Youcanhave a witness for your consent to donate, but it is not required1.Some states may require a witness signature on your donor card or registration form, but others do not
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: While additional staff may be needed, the primary focus during a mass casualty event is triage and immediate care. Choice B rationale: Media relations are important, but the nurse's priority is direct patient care. Choice C rationale: Assessing incoming clients and determining their medical needs is crucial for prioritizing care and allocating resources effectively. Choice D rationale: Discharging stable clients may be necessary in extreme circumstances, but it is not the immediate priority. The focus should be on providing care to the influx of injured patients.
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