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 C

Explanation

A) Looking at the client from the side, observe the size and shape of the chest wall:
This action is more related to inspecting the physical appearance and symmetry of the chest wall but does not assess tactile fremitus.

B) Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation:
This action may be more relevant for assessing subcutaneous emphysema (crepitus) but is not the correct method for assessing tactile fremitus.

C) Place the palm of the hand on the chest wall to feel vibrations while the client speaks:
This is the correct action to assess tactile fremitus. By placing the palm of the hand on various areas of the chest wall while the client repeats a phrase such as "ninety-nine," the nurse can feel for vibrations. Increased tactile fremitus can indicate consolidation, as seen in pneumonia.

D) Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly:
This action involves auscultation, which is important for assessing breath sounds but does not assess tactile fremitus directly.

A. Hyperactive bowel sounds. B. A minor variation. C. Possible renal artery stenosis. D. Normal borborygmus sounds.

Correct Answer is C

Explanation

A) Hyperactive bowel sounds:
Hyperactive bowel sounds are typically characterized by loud, high-pitched gurgles heard throughout the abdomen. They are often associated with increased intestinal motility, such as in gastroenteritis or diarrhea, rather than a low-pitched blowing sound in the upper midline area.

B) A minor variation:
A minor variation may refer to a benign finding or a slight deviation from the norm. However, a low-pitched blowing sound in the upper midline area would not typically be considered a minor variation and may warrant further investigation.

C) Possible renal artery stenosis:
A low-pitched blowing sound in the upper midline area could indicate a renal artery bruit, which is a sign of renal artery stenosis. Renal artery stenosis is a narrowing of the renal artery, often due to atherosclerosis, which can lead to decreased blood flow to the kidneys. A renal artery bruit may be auscultated over the renal arteries and is indicative of turbulent blood flow through the narrowed artery.

D) Normal borborygmus sounds:
Borborygmi are normal bowel sounds characterized by gurgling, rumbling, or growling noises produced by the movement of gas and fluid in the intestines. However, a low-pitched blowing sound in the upper midline area would not typically be described as normal borborygmi. Borborygmi are usually heard at a higher frequency and throughout the abdomen.

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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]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is C

Explanation

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

Correct Answer is C

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

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?

When evaluating a client's rectal bleeding, which findings should the nurse document?

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client's skin for which finding?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

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]