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A nurse is performing a health screening for a client who weighs 90 kg (198 lb) and is 160 cm (63 in) tall. The nurse should classify the client's BMI as falling into which of the following categories?

Overweight

Extremely obese

Normal

Obese

Answer and Explanation

The Correct Answer is D

To calculate the BMI:

Convert weight to kilograms: 90 kg (198 lb)
Convert height to meters: 160 cm = 1.6 m
Use the BMI formula: BMI = weight (kg) / height (m)^2

BMI = 90 / (1.6)^2 BMI = 90 / 2.56 BMI ≈ 35.2

A. Overweight: Overweight is typically classified with a BMI from 25 to 29.9. This BMI is higher.
B. Extremely obese: The term "extremely obese" is not commonly used. The classification for a BMI above 40 would be "extremely obese."
C. Normal: A normal BMI ranges from 18.5 to 24.9. The calculated BMI is higher than this range.
D. Obese: A BMI of 35.2 falls into the category of obesity (30 to 39.9).

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Correct Answer is C

Explanation

A. "The client's postoperative antibiotic was administered." While this information is important, it is not typically included in the change-of-shift report unless there were specific issues related to antibiotic administration (e.g., allergic reactions, missed doses).
B. "The client's partner came to visit today." While this information might be relevant to the client’s social and emotional well-being, it is not critical for the shift report regarding clinical care.
C. "At 2200, the client's IV fluid bag and tubing will need replacing." This statement is important for continuity of care and should be included in the report to ensure that the next shift is aware of necessary actions.
D. "Colonoscopy was performed 48 hours ago." This information is relevant for understanding the client’s postoperative status but is less immediate compared to other details such as current medication administration or upcoming needs.

A. Decrease in heart rate B. Increase in vagal nerve tone C. Decrease in respiratory rate D. Increase in muscle tone

Correct Answer is D

Explanation

A. Decrease in heart rate: Acute pain typically causes an increase in heart rate, not a decrease.
B. Increase in vagal nerve tone: An increase in vagal nerve tone can actually result in a decreased heart rate and is not a direct indicator of acute pain.
C. Decrease in respiratory rate: Acute pain usually causes an increase in respiratory rate, not a decrease.
D. Increase in muscle tone: This is correct. An increase in muscle tone can indicate acute pain as the body tenses in response to pain.

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A nurse is performing a health screening for a client who weighs 90 kg (198 lb) and is 160 cm (63 in) tall. The nurse should classify the client's BMI as falling into which of the following categories?

Nursing Test Bank

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