In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care?

Reference Range:

Underweight: BMI is less than 18.5; Normal weight: BMI is 18.5 to 24.9; Overweight: BMI is 25 to 29.9; Obese: BMI is 30 or more

Fluid volume excess.

Unbalanced nutrition, less than body needs.

Unbalanced nutrition, greater than body needs.

Fluid volume deficit.

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Fluid volume excess is incorrect. Fluid volume excess refers to an overabundance of fluid in the body, leading to symptoms such as edema, weight gain, and hypertension. However, a BMI of 14 kg/m^2 indicates underweight, not fluid volume excess. Therefore, this choice is incorrect.
Choice B Reason:
Unbalanced nutrition, less than body needs is correct. A BMI of less than 18.5 indicates underweight according to the provided reference range. Underweight individuals often do not consume enough nutrients to meet their body's needs, leading to potential nutritional deficiencies. Therefore, the nursing problem of "Unbalanced nutrition, less than body needs" is appropriate for addressing the client's low BMI.
Choice C Reason:
Unbalanced nutrition, greater than body needs is incorrect. This choice would be more applicable if the client's BMI indicated overweight or obesity, as it suggests an excess intake of nutrients relative to the body's needs. However, a BMI of 14 kg/m^2 indicates underweight, not excess weight. Therefore, this choice is incorrect.
Choice D Reason:
Fluid volume deficit is incorrect. Fluid volume deficit refers to a decreased amount of fluid in the body, leading to symptoms such as dehydration, decreased urine output, and hypotension. However, a low BMI does not necessarily indicate fluid volume deficit; it primarily reflects undernutrition. Therefore, this choice is incorrect.

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Correct Answer is A

Explanation

Choice A Reason:
Asking the client to recall what was consumed for lunch and breakfast is appropriate. Asking the client to recall recent events, such as what was consumed for lunch and breakfast, helps assess their short-term memory. Difficulty recalling recent events or recent medication doses may indicate emery impairment or cognitive decline, which could be contributing to the reported confusion and forgetfulness. This assessment provides valuable information about the client's ability to retain and recall recent information, which is pertinent to understanding the extent of memory impairment.
Choice B Reason:
Asking the spouse how often the pain medication is to be taken is inappropriate. While asking the spouse about the pain medication regimen provides information about the client's medication schedule, it does not directly assess the client's memory. Additionally, relying solely on the spouse's report may not accurately reflect the client's memory abilities or recall of medication instructions.
Choice C Reason:
Request for the spouse to write down the things the client forgets is inappropriate. Asking the spouse to write down forgotten items may help track memory lapses but does not directly assess the client's memory during the home visit. It also does not provide real-time information about the client's ability to recall recent events or medication instructions.
Choice D Reason:
Observing client ability to perform activities of daily living (ADLs) is inappropriate. Assessing the client's ability to perform activities of daily living (ADLs) is important for evaluating overall functional status but may not specifically target memory assessment. While memory impairment can impact ADL performance, it is not the most direct assessment for evaluating memory specifically during the home visit.

A. Stand directly in front of the client and ask about any hearing loss. B. Obtain a tuning fork to complete Rinne and Weber tuning fork tests. C. Begin to orient the client to her surroundings in the hospital room. D. Perform a mental status exam to assess the client's thought processes.

Correct Answer is A

Explanation

Choice A Reason:
Standing directly in front of the client and ask about any hearing loss is appropriate because the client's behavior of ignoring questions from the nurse and speaking loudly to her son suggests a potential hearing impairment. Standing directly in front of the client allows for better visibility of facial expressions and lip movements, which can aid in communication for individuals with hearing loss. Asking about any hearing loss helps the nurse gather important information to adapt communication strategies effectively.
Choice B Reason:
Obtaining a tuning fork to complete Rinne and Weber tuning fork tests involves conducting hearing tests using a tuning fork to assess for conductive or sensorineural hearing loss. While these tests are valuable for diagnosing hearing impairments, they are typically performed after obtaining a thorough history and initial assessment, including asking about any hearing loss. Therefore, this option is not the first action to take when communication difficulties are observed.
Choice C Reason:
Beginning to orient the client to her surroundings in the hospital room involves providing orientation to the client about her surroundings, which is important for promoting comfort and reducing anxiety, especially in a new environment like a hospital room. However, addressing potential hearing loss is the priority when the client's behavior suggests difficulty in communication. Once hearing impairment is ruled out or addressed, orientation to the surroundings can be initiated.
Choice D Reason:
Performing a mental status exam to assess the client's thought processes involves assessing the client's cognitive function and thought processes, which is important for understanding the client's overall mental status. While assessing mental status is an essential aspect of comprehensive nursing assessment, it may not directly address the observed communication difficulties related to potential hearing impairment. Therefore, addressing potential hearing loss should be the first action to ensure effective communication before proceeding with a mental status exam.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Correct Answer is A

Explanation

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