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?"

Answer and Explanation

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.

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Correct Answer is D

Explanation

a. Interrupt the handwashing and insist the client come to meals with everyone else. Interrupting ritualistic behaviors abruptly can increase distress and is not recommended. It may also reinforce the belief that the ritual is necessary.
b. Provide the client's meals later and after the other clients have eaten. This is not appropriate as it accommodates the OCD behavior and disrupts the mealtime routine for other clients.
c. Notify the client when it is 30 minutes before the meal so they can begin their handwashing. This is not appropriate as it enables the ritualistic behavior and may lead to increased anxiety if the client feels rushed to complete their ritual.
d. Allow the client to continue as is but provide them access to the kitchen. This is correct because it respects the client's autonomy while also providing an opportunity for gradual exposure therapy, where the client can work with the nurse to gradually reduce the time spent on rituals.

A. time of day. B. client's perception of the event. C. availability of adequate coping mechanisms. D. availability of supports.

Correct Answer is ["B","C","D"]

Explanation

a. time of day. The time of day is not a significant factor in determining whether a situation will be perceived as a crisis.
b. client's perception of the event. This is correct because an individual's perception of an event greatly influences whether it is experienced as a crisis.
c. availability of adequate coping mechanisms. This is correct because having effective coping mechanisms can mitigate the impact of a stressful situation and prevent it from becoming a crisis.
d. availability of supports. This is correct because having a supportive network can help individuals manage stress and reduce the likelihood of a crisis.
e. location of a treatment centre. While access to treatment is important, the immediate experience of a crisis is more influenced by perception, coping mechanisms, and support systems than the location of a treatment centre.

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The nurse is assessing an alert and independent older client for the risk of malnutrition. What item is most appropriate to assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client, who is newly admitted with Obsessive-Compulsive Disorder, washes their hands ritualistically before any activity. They arrive late to meals and does not have time to finish eating. The appropriate nursing action would be to:

Correct Answer is D

Explanation

The nurse understands that whether or not a client experiences crisis as a result of a stressful situation depends on the: (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

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