A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

Healthy weight

Overweight

Underweight

Obesity class 1

Answer and Explanation

The Correct Answer is C

A. Healthy weight – A BMI between 18.5 and 24.9 is classified as healthy. Since the client's BMI is 17.2, they do not fall within this range.

B. Overweight – Overweight is defined as a BMI between 25.0 and 29.9. The client's BMI of 17.2 is far below this range.

C. Underweight – A BMI below 18.5 is classified as underweight. Since the client's BMI is 17.2, they fall into this category. Clients with Crohn’s disease often experience malabsorption and weight loss, leading to a low BMI.

D. Obesity class 1 – Obesity is categorized as a BMI of 30.0 or higher. The client’s BMI is far below this classification.

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Correct Answer is C

Explanation

A. Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing.

B. Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus.

C. Frequent swallowing – This is the priority finding because it may indicate active bleeding at the surgical site. Children may not always report bleeding but may swallow frequently as blood drips into their throat. If left undetected, excessive bleeding can lead to hemorrhage and airway compromise. The nurse should inspect the throat immediately and notify the provider.

D. Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.

A. Suctioning device B. Bite block C. Vest restraint D. Padded tongue blade

Correct Answer is A

Explanation

A. Suctioning device – Correct. A suctioning device is essential to clear the airway in case of excessive secretions during or after a seizure.

B. Bite block – Incorrect. Bite blocks are not used during seizures as they can cause injury. Nothing should be placed in the client’s mouth during a seizure.

C. Vest restraint – Incorrect. Restraints should not be used on clients with seizure disorders as they can cause injury.

D. Padded tongue blade – Incorrect. Tongue blades should never be inserted into the mouth of a seizing client due to the risk of airway obstruction and oral trauma.

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A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

Nursing Test Bank

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