The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m2. Based on this BMI, what should the nurse deduce about this client's general health?

Reference Range: Body Mass Index (BMI) [Normal 18.5 to 24.9 kg/m2]

Obese, serious threat to well-being.

Appropriate weight for height, good general health.

Extreme obesity, at risk for multiple co-morbidities.

Undernutrition, at risk for malnutrition.

Answer and Explanation

The Correct Answer is A

A) Obese, serious threat to well-being: A BMI of 32 kg/m² places the client in the category of obesity (BMI ≥ 30 kg/m²). Obesity is a significant health concern associated with increased risks for various conditions such as cardiovascular disease, diabetes, hypertension, and certain cancers. The client's BMI indicates that she is obese, which poses a serious threat to her overall well-being and health.

B) Appropriate weight for height, good general health: This is incorrect because a BMI of 32 kg/m² does not fall within the normal range of 18.5 to 24.9 kg/m². The client is not at an appropriate weight for her height and is not considered to be in good general health based on this BMI.

C) Extreme obesity, at risk for multiple co-morbidities: While a BMI of 32 kg/m² does indicate obesity, it does not reach the threshold for extreme obesity (BMI ≥ 40 kg/m²). Therefore, the client is not categorized as extremely obese, although she is still at risk for several co-morbidities associated with obesity.

D) Undernutrition, at risk for malnutrition: This is incorrect because a BMI of 32 kg/m² is indicative of excess weight, not undernutrition or malnutrition. The client's BMI suggests an over-nutrition status rather than undernutrition.

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Correct Answer is B

Explanation

B. Cardiac enlargement:
This is the most likely interpretation of the findings. A significant area of dullness across a larger portion of the chest, as described, suggests that the heart is enlarged (cardiomegaly). Enlargement of the heart may result from various conditions, such as heart failure, hypertension, or valvular disease, leading to increased cardiac size and the shift in the percussion borders. This could indicate that the heart has expanded beyond its normal anatomical limits, and further assessment, such as imaging, would be necessary to confirm the diagnosis.

A. Ambulatory and disoriented to place. B. Wandering behavior with flat affect. C. Appears confused and depressed. D. Demonstrates signs of early dementia.

Correct Answer is B

Explanation

Answer: B. Wandering behavior with flat affect.

Rationale:

A. Ambulatory and disoriented to place:
This documentation suggests that the client is physically able to walk but does not adequately capture the behavioral aspect of the observation. While the client may be ambulatory, merely stating disorientation does not convey the lack of engagement or emotional response, which is crucial in understanding the client's mental state and overall condition.

B. Wandering behavior with flat affect:
This option accurately reflects the observed behavior of the client. "Wandering behavior" captures the aimless walking, while "flat affect" describes the lack of emotional expression indicated by the blank stare. This documentation provides a clearer picture of the client's mental status, which is vital for further assessment and intervention.

C. Appears confused and depressed:
While confusion may be a relevant aspect of the client's condition, this statement lacks specificity regarding the observed behaviors. Depression cannot be accurately concluded from the blank expression alone, as it may not reflect sadness or mood but rather a cognitive or perceptual issue. More objective descriptors would enhance the clarity of the documentation.

D. Demonstrates signs of early dementia:
This option makes a definitive statement about the possibility of early dementia without sufficient evidence from the observation. While aimless walking and a blank expression can be associated with cognitive decline, diagnosing dementia requires comprehensive assessment and evaluation beyond a single observation. This phrasing could mislead healthcare providers regarding the client’s condition and may lead to premature conclusions about the client’s cognitive health.

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The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m2. Based on this BMI, what should the nurse deduce about this client's general health? Reference Range: Body Mass Index (BMI) [Normal 18.5 to 24.9 kg/m2]

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Naxlex Comprehensive Predictor Exams

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is B

Explanation

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?

Correct Answer is B

Explanation

Rationale:

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The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m2. Based on this BMI, what should the nurse deduce about this client's general health?

Reference Range: Body Mass Index (BMI) [Normal 18.5 to 24.9 kg/m2]