A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Troponin

Creatine kinase

Total bilirubin

Albumin

Answer and Explanation

The Correct Answer is D

A.   Troponin is a marker for cardiac muscle damage. It is not directly related to anorexia and malnutrition.
B.   Creatine kinase is also a marker for muscle damage, particularly in conditions like heart attacks or muscular disorders. It is not directly related to anorexia and malnutrition.
C.   Total bilirubin is related to liver function. While severe malnutrition can affect liver function, it's not the primary marker for malnutrition.
D.   Albumin is a protein synthesized by the liver and is an important indicator of nutritional status. In cases of malnutrition, especially protein-calorie malnutrition, serum albumin levels tend to decrease. This is due to the body's decreased ability to synthesize proteins when there is a lack of adequate nutrition.

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Correct Answer is C

Explanation

A. Measuring the gastric residual is a common practice before administering enteral feedings. It helps to assess if the client's stomach is emptying properly and if there is any buildup of undigested formula. This is important in identifying delayed gastric emptying, which can lead to complications if not addressed.
B. To remove gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. The main concern is to assess the rate of stomach emptying.
C. To confirm the placement of the NG tube is typically done using other methods, such as pH testing or an X-ray. While aspirating stomach contents through the tube can help confirm placement, it is not the primary purpose of measuring gastric residual.
D. To determine the client's electrolyte balance is not related to the purpose of measuring gastric residual. Electrolyte balance is typically assessed through blood tests and clinical signs and symptoms.

A. He is hard of hearing. B. Confusion C. Pain D. Language barrier E. None F. None

Correct Answer is B

Explanation

A. He is hard of hearing:
This is unlikely. While hearing impairment could explain some difficulty in communication, it would not explain the flinching upon abdominal palpation or the wandering behavior. Hearing-impaired clients typically respond to nonverbal cues or attempt to communicate their understanding in other ways.

B. Confusion:
This is correct. The client's wandering behavior, lack of verbal response, and smiling/nodding without clear understanding are indicative of confusion, which is common in older adults experiencing delirium, dementia, or other cognitive impairments. The flinching during abdominal palpation suggests a physical issue, but the client's inability to articulate his discomfort further supports confusion as a contributing factor.

C. Pain:
While pain could explain the flinching during palpation, it does not account for the wandering behavior or the lack of meaningful verbal communication. Pain may coexist with confusion but is not the primary explanation for his overall behavior.

D. Language barrier:
A language barrier could explain difficulty in verbal communication, but it does not account for the wandering behavior or the flinching upon palpation. Additionally, the family’s ability to communicate with the healthcare team suggests this is not the most likely factor

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A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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