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 A

Explanation

A. This is a condition where the skin becomes hyperemic and hot after the application of heat. It's a sign of tissue damage and can lead to burns. Assessing for rebound phenomenon before applying a heating pad is crucial to prevent further injury.
B. While assessing range of motion can be helpful in determining the effectiveness of heat therapy, it's not the most important factor to consider before application.
C. Muscle strength and tone are not directly related to the risk of skin damage from heat therapy.
D. While neurosensory impairment can affect a client's ability to perceive heat and respond to pain, assessing for rebound phenomenon is a more direct way to evaluate the risk of skin damage.

A. Notify the hospital ethical committee to assist with client's wishes. B. Have resuscitation equipment readily available. C. Document healthcare provider's refusal to honor client's wishes. D. Facilitate a meeting between the healthcare provider and the spouse.

Correct Answer is A

Explanation

A. The ethics committee can provide guidance on how to navigate the conflict between the healthcare provider’s beliefs and the client's documented wishes. The committee can mediate discussions and help ensure that the client's rights and preferences are respected according to legal and ethical standards.
B. While having resuscitation equipment available might be relevant if there is a sudden need for emergency intervention, it does not directly address the issue of honoring the client’s living will. This action does not resolve the ethical conflict or ensure that the client’s wishes are respected.
C. Documenting the healthcare provider’s refusal is important for legal and medical records but does not resolve the situation or ensure that the client’s wishes are respected. Documentation alone does not address the ethical conflict or take action to honor the client’s living will.
D. Facilitating a meeting between the healthcare provider and the spouse could be beneficial for discussing the client’s wishes and potentially reaching a mutual understanding. However, if the healthcare provider remains unwilling to honor the living will despite such discussions, this action alone may not resolve the conflict.

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Naxlex Comprehensive Predictor Exams

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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