The nurse is assessing an older female adult's client's nutritional status. Which finding indicates that the client has a nutritional deficiency?

Reference Ranges:

Hemoglobin [12 to 16 g/dl (120 to 160 g/L)]

Hematocrit 37% to 47% (0.37 to 0.47 volume fraction)]

Albumin [3.5 to 5.0 g/dl (35 to 50 g/L)]

Serum transferrin [250 to 380 mg/dl (2.5 to 3.80 g/L)]

A hemoglobin (Hgb) of 11.8 g/dL (118 g/L) and hematocrit (Hct) of 34% (0.34).

Low weight as determined from a height/weight comparison chart.

Decreased lean body mass compared to results of 10 years ago.

Serum albumin of 3 g/dL (30 g/L) and serum transferrin of 180 mg/dL (1.8 g/L).

Answer and Explanation

The Correct Answer is D

A.   Hemoglobin (Hgb) and Hematocrit (Hct) are important indicators of anemia, which can be caused by nutritional deficiencies such as iron, vitamin B12, or folate deficiencies. For an older adult female, the reference range for hemoglobin is 12 to 16 g/dL, and the hematocrit range is 37% to 47%. A hemoglobin of 11.8 g/dL and a hematocrit of 34% are below the normal range, indicating potential anemia, which could be related to nutritional deficiencies.
B.   Weight loss or being underweight can be a sign of nutritional deficiency, particularly if it is unintentional. However, this option lacks specific details about the extent of weight loss and its relation to other indicators. Weight alone does not provide complete information about nutritional deficiencies without additional context, such as changes in weight over time or body composition.
C.   A decrease in lean body mass can be indicative of malnutrition or a prolonged deficiency in protein or overall caloric intake. While it is an important indicator of nutritional status, it reflects long-term changes and may not immediately show acute deficiencies.
D.   Serum albumin and serum transferrin are biomarkers of nutritional status. The reference range for serum albumin is 3.5 to 5.0 g/dL, and for serum transferrin, it is 250 to 380 mg/dL. A serum albumin level of 3 g/dL and a serum transferrin level of 180 mg/dL are both below the normal range, indicating possible malnutrition or protein deficiency.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. While practicing strength-building exercises for the arms, such as isometric exercises for the biceps and triceps, is beneficial for overall crutch use, it does not directly indicate proper crutch walking technique.
B. This choice is not correct for a three-point gait, especially in the case of a broken foot. In a three-point gait, the client should avoid bearing weight on the affected leg, as this gait is used to promote healing of a non-weight-bearing limb.
C. This behavior indicates a correct understanding of crutch walking. In the three-point gait, the client should bear weight on the crutches' handles and not on the armpits, which helps prevent nerve damage and provides better stability.
D. While it is important for safety to ensure that the rubber tips of the crutches are intact and not worn out, this behavior does not directly demonstrate the client’s understanding of the three-point gait technique.

A. Explain the respiratory problems that can occur with morphine use. B. Recommend asking the healthcare professional for a patient-controlled analgesia (PCA) pump. C. Provide client with a schedule of around-the-clock prescribed analgesic use. D. Teach family how to evaluate the effectiveness of analgesics.

Correct Answer is C

Explanation

A. Morphine is a potent opioid used for pain relief, but it can have side effects, including respiratory depression. While it is important to be aware of and discuss potential side effects, focusing on
respiratory problems might increase the client’s anxiety about using the medication.
B. A PCA pump allows patients to self-administer pain medication within prescribed limits, providing more control over pain management. However, PCA pumps are typically used in hospital settings and may not be practical or appropriate for home hospice care.
C. Providing a schedule for around-the-clock analgesic use is a practical and effective approach to pain management. It ensures that the client receives consistent pain relief and helps prevent the pain from becoming unmanageable.
D. Teaching the family to evaluate the effectiveness of analgesics is important for ongoing pain management. This includes recognizing signs of pain relief and potential side effects. However, this action might be more relevant once pain management is underway and requires follow-up, rather than addressing the immediate concern of managing pain effectively from the start.

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