The nurse is assessing a patient's bowel sounds.
The nurse does not hear anything for 30 seconds.
How should the nurse document this finding?

Choice A rationale

Regulating nerve cell transmission is primarily a function of electrolytes like sodium, potassium, and calcium, as well as neurotransmitters. While fats are components of nerve cell membranes, they do not directly regulate the transmission of nerve impulses.

Choice B rationale

Converting to sugar (glucose) to provide energy is the primary function of carbohydrates. While fats can be metabolized for energy, they are broken down into fatty acids and glycerol, not directly into glucose. Gluconeogenesis can convert glycerol to glucose, but this is a secondary energy pathway.

Choice C rationale

Fats are crucial for the absorption of fat-soluble vitamins (A, D, E, and K). These vitamins are lipophilic, meaning they dissolve in fats. Dietary fat is necessary in the small intestine to emulsify these vitamins, allowing them to be absorbed across the intestinal lining into the bloodstream.

Choice D rationale

Building and repairing tissue is the primary function of proteins, which are composed of amino acids. While fats are components of cell membranes and contribute to overall cell structure, they do not play the main role in tissue synthesis and repair.

Choice A rationale

Increased hair growth is typically associated with hormonal imbalances, such as an excess of androgens, or certain medications, not generally with undernutrition. Adequate nutrition is essential for maintaining normal hair growth cycles. Nutritional deficiencies often lead to hair thinning or loss, rather than increased growth.

Choice B rationale

A sore, inflamed buccal cavity, also known as stomatitis or mucositis, can be a direct consequence of inadequate nutrition, particularly deficiencies in B vitamins, iron, and vitamin C. These nutrients are crucial for maintaining the health and integrity of the oral mucous membranes. Inflammation and soreness can make eating painful, further contributing to poor nutrient intake.

Choice C rationale

Adequate nutrient or food intake directly contradicts the nursing diagnosis of imbalanced nutrition, less than body requirements. This finding would indicate that the patient's nutritional needs are being met, and the diagnosis would be inaccurate. The presence of dysphagia suggests difficulty in achieving adequate intake.

Choice D rationale

A weight within 10% of ideal body weight suggests that the patient's nutritional status is likely adequate, not less than body requirements. While dysphagia can lead to weight loss, a weight within the normal range indicates that the patient has been able to maintain their weight despite potential swallowing difficulties.