A nurse is collecting data from a client who is malnourished due to inflammatory bowel disease. Which of the following findings should the nurse expect?

Brittle hair

Yellow conjunctivae

Bradycardia

Clubbing of the fingernails

Answer and Explanation

The Correct Answer is A

A. Brittle hair: Malnutrition often leads to protein and micronutrient deficiencies, which impair hair growth and texture, resulting in dry, brittle, or thinning hair. This is a common visible sign in clients with poor nutritional status.

B. Yellow conjunctivae: Yellowing of the conjunctivae typically indicates jaundice due to liver dysfunction or hemolysis, not malnutrition from inflammatory bowel disease. It reflects bilirubin accumulation rather than nutrient deficiency.

C. Bradycardia: While bradycardia may occur in severe starvation or electrolyte imbalance, it is not a consistent or early indicator of malnutrition from inflammatory bowel disease. It requires further context to be clinically relevant.

D. Clubbing of the fingernails: Clubbing is associated with chronic hypoxia or pulmonary/cardiac conditions. It is not commonly linked to malnutrition or inflammatory bowel disease unless there are severe complications such as chronic anemia or hypoxia.

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Correct Answer is B

Explanation

A. The grounding pad is positioned near the client's surgical site: The grounding pad for electrosurgery should be placed on a large, well-vascularized muscle mass away from the surgical site to ensure proper dispersion of electrical current and prevent burns. Placing it near the site increases risk of injury.

B. The client is positioned to minimize pressure on the skin: Proper positioning during surgery helps prevent pressure ulcers and nerve injuries by reducing prolonged pressure on bony prominences and delicate tissues, supporting a safe and therapeutic environment.

C. The client is covered with a cooling blanket during surgery: Maintaining normothermia is critical; cooling blankets can cause hypothermia, which increases the risk of complications such as infection and coagulopathy. Warm blankets or forced-air warming devices are preferred.

D. The client's surgical site is shaved with a razor: Shaving with a razor can cause microabrasions that increase the risk of surgical site infections. Clipping hair with electric clippers is the recommended practice to reduce infection risk.

A. Tell the client to think about something else. B. Tell the client that everything will be okay. C. Ask the client to describe their support system. D. Ask the client why they're unable to cope.

Correct Answer is C

Explanation

A. Tell the client to think about something else: Redirecting the client's thoughts without addressing their emotional distress can be dismissive. It does not support emotional processing or help the nurse assess the client’s coping needs.

B. Tell the client that everything will be okay: Offering false reassurance minimizes the client’s feelings and may hinder open communication. It does not validate their experience or help develop coping strategies.

C. Ask the client to describe their support system: Exploring the client’s support system helps assess available emotional and practical resources. This information is essential in planning appropriate interventions and enhancing coping capacity.

D. Ask the client why they're unable to cope: "Why" questions can make clients feel defensive and judged. It is more therapeutic to use open-ended questions that invite sharing without implying blame.

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A nurse is collecting data from a client who is malnourished due to inflammatory bowel disease. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client during surgery. Which of the following should the nurse identify as supporting a safe, therapeutic environment?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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