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. Aphasia: Aphasia is a language disorder that affects a person's ability to communicate. It does not involve the creation of false memories or stories.
b. Delirium: Delirium is an acute, often sudden change in mental status that can cause confusion and impaired attention, but it is not characterized by the fabrication of detailed stories.
c. Apraxia: Apraxia is a motor disorder where a person has difficulty with the motor planning to perform tasks or movements. It does not involve creating false stories.
d. Confabulation: Confabulation involves the creation of false memories or stories without the intention to deceive. This is common in Alzheimer's disease as the brain attempts to fill gaps in memory.

A. "Make sure you concentrate on taking slow, deep, cleansing breaths." B. "Wear sunscreen and try to avoid midday sun exposure." C. "Watch your diet and try to engage in some regular physical activity." D. "Rise slowly when you change position from lying to sitting or sitting to standing."

Correct Answer is D

Explanation

a. While taking slow, deep breaths can help with relaxation and possibly with managing anxiety or panic attacks, it is not directly addressing the combined side effects of these medications.
b. Wearing sunscreen and avoiding midday sun exposure is important to prevent photosensitivity reactions caused by some antipsychotics, but it is not related to the combined effects of antipsychotics and beta-blockers.
c. Watching diet and engaging in physical activity are generally good health practices but do not specifically address the combined side effects of these medications.
d. "Rise slowly when you change position from lying to sitting or sitting to standing." Both antipsychotics and beta-adrenergic blocking agents can cause orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or even fainting. Advising the client to rise slowly helps to prevent these effects and ensures the client’s safety

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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?

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Naxlex Comprehensive Predictor Exams

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