The nurse is assessing an alert and independent older client for the risk of malnutrition. What item is most appropriate to assess?
"Where do you buy your food?"
"Does someone else prepare your meals?"
"Tell me what you eat in a typical day.
Are you taking any medications that change your taste of foods?"
The Correct Answer is C
a. "Where do you buy your food?" While this provides information about food access, it doesn’t directly assess nutritional intake.
b. "Does someone else prepare your meals?" This might provide insight into the client's independence, but it doesn't directly assess nutritional intake.
c. "Tell me what you eat in a typical day." This directly assesses the client’s dietary intake and provides a comprehensive view of their nutrition status.
d. "Are you taking any medications that change your taste of foods?" This is relevant but more specific to one aspect of dietary intake. It does not provide a full picture of the client’s nutritional status like option c.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Psychotic disorder: Schizophrenia is a well-defined psychotic disorder characterized by delusions, hallucinations, and disorganized thinking, but it doesn't specifically address the mood component present in this case.
b. Schizoaffective disorder: Schizoaffective disorder is characterized by symptoms of both schizophrenia (such as delusions and hallucinations) and mood disorders (such as depression or mania). The presence of delusional thinking and visual hallucinations, combined with periods of depression and suicidal ideations, fits the profile of schizoaffective disorder.
c. Paranoid disorder: Paranoid disorder is characterized by a pervasive pattern of suspicion and distrust, but it doesn't necessarily involve hallucinations or disorganized thinking like schizophrenia.
d. Schizophreniform disorder: Schizophreniform disorder is similar to schizophrenia but with a shorter duration of symptoms (less than 6 months). The prompt doesn't specify the duration, making schizophrenia a more likely diagnosis.
Correct Answer is D
Explanation
a. Akathisia and hypersalivation. These side effects are uncomfortable but generally not immediately life-threatening.
b. Dry mouth and urinary retention. These side effects are concerning and should be monitored, but they do not typically require immediate intervention unless severe.
c. Akinesia and insomnia. While akinesia (lack of movement) and insomnia are significant, they are not immediately life-threatening symptoms.
d. Sore throat, fever, and malaise. This choice is correct because these symptoms could indicate agranulocytosis, a potentially life-threatening side effect of clozapine that requires immediate medical intervention.
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