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A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?

Diplopia

Hyperproteinemia

Cachexia

Hypermagnesemia

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Diplopia is incorrect. Diplopia is double vision and is not a specific sign of malnutrition.

Choice B Reason:

Hyperproteinemia is incorrect - Malnutrition often leads to hypoalbuminemia (low levels of albumin, a protein), not hyperproteinemia.

Choice C Reason:

Cachexia is correct. Cachexia refers to a state of severe malnutrition and muscle wasting that can occur in individuals with chronic illnesses, especially advanced cancer, heart failure, or certain inflammatory conditions. It is characterized by significant weight loss, muscle atrophy, weakness, and fatigue. Cachexia goes beyond simple malnutrition and is a more severe manifestation of nutritional deficiency.

Choice D Reason:

Hypermagnesemia is incorrect - Malnutrition is more likely to cause deficiencies in minerals like magnesium, not excess levels (hypermagnesemia).

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Correct Answer is A

Explanation

Choice A reason:

Confirming the correct position of the line by obtaining a blood sample is appropriate. Inserting a central venous catheter is a procedure that involves placing a catheter into a large vein, typically in the neck, chest, or groin. Confirming the correct placement is crucial to prevent complications such as pneumothorax (lung collapse) or catheter misplacement.

Choice B reason:

Instructing the client to cough as the catheter is inserted is not a standard practice during central venous catheter insertion and could lead to unnecessary complications.

Choice C reason:

Placing the head of the client's bed lower than the foot (Trendelenburg position) is not a standard practice during central venous catheter insertion and would not be helpful for this procedure.

Choice D reason:

Cleansing the site with hydrogen peroxide is not the recommended method for central venous catheter insertion. Typically, a sterile technique and appropriate antiseptic solution are used to reduce the risk of infection.

A. Obtain consent for surgery. B. Insert an NG tube. C. Apply antiembolic stockings D. insert an indwelling armory catheter

Correct Answer is A

Explanation

Choice A reason:

Obtaining consent for surgery is the correct answer. Obtaining informed consent for surgery is a critical and ethical step to ensure the client's rights are respected and that necessary medical interventions can be performed. However, in cases where the client is unable to provide consent due to their level of intoxication, the nurse should follow established protocols for obtaining consent from a legal guardian or

Choice B reason:

Insert an NG tube is incorrect. Inserting a nasogastric (NG) tube might be a necessary step in preparing a client for surgery in certain cases, but it is not the top priority in this situation. Obtaining consent for surgery takes precedence.

Choice C reason:

Applying ant embolic stockings is incorrect. Applying ant embolic stockings, also known as compression stockings, is an important measure to prevent blood clots (deep vein thrombosis) during and after surgery. However, obtaining consent for surgery is more urgent in an emergency situation.

Choice D reason:

Inserting an indwelling urinary catheter is incorrect. Inserting a urinary catheter might be necessary to monitor the client's urinary output during surgery, but obtaining consent for surgery is the priority action.

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A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?

Nursing Test Bank

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