The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?

Body mass index (BMI) of 17.

Decrease in the appetite.

Dry mucosal membranes.

Weight of 227 pounds (103 kg).

Answer and Explanation

The Correct Answer is A

Choice A

Body mass index (BMI) of 17 is the correct finding. A low Body Mass Index (BMI) is a common indicator of malnutrition. BMI is a measurement that considers a person's weight in relation to their height. A BMI of 17 suggests that the person is underweight, which can be indicative of malnutrition. Malnutrition is characterized by inadequate intake of calories, protein, vitamins, and minerals that are essential for maintaining health and well-being.

Choice B

Decrease in appetite is not correct finding. While a decrease in appetite might contribute to malnutrition, it's a symptom rather than a definitive indicator.

Choice C

Dry mucosal membranes are not the correct finding. Dry mucosal membranes can be related to dehydration or other conditions, but they are not specific enough to confirm malnutrition on their own.

Choice D

Weight of 227 pounds (103 kg) is not the correct finding. This weight is not necessarily indicative of malnutrition on its own. It's important to consider the individual's height, BMI, and other factors when assessing malnutrition.

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

Explanation

Choice A

Pickles, blackberries, seeds are not appropriate. None of these foods are particularly high in calcium. Pickles and blackberries are not significant sources of calcium, and while some seeds contain calcium, they are not among the best sources.

Choice B

Buttermilk, spinach, milk: These foods are good sources of dietary calcium is appropriate. Milk and buttermilk are commonly consumed dairy products that contain calcium. Spinach, while not as high in calcium as dairy products, still contributes to calcium intake.

Choice C

Pickled olives, spam, nuts are not appropriate. These foods are not known for being high in calcium. Additionally, some foods like pickled olives and spam may have high sodium content, which can affect calcium balance.

Choice D

Fresh meats, fresh turkey, fresh chicken is appropriate. Fresh meats, such as turkey and chicken, provide some calcium, although not as much as dairy products. They also contribute to overall nutritional intake.

Choice E

Cheese spread, processed cheese, cheese is appropriate. Dairy products like cheese, especially processed cheese and cheese spread, are good sources of calcium. They can be effective in increasing calcium intake to address hypocalcaemia.

A. Send fluid specimen to the lab. B. Withdraw the NGT and reinsert. C. Connect the NGT to wall suction. D. Determine pH value of specimen.

Correct Answer is A

Explanation

Choice A

Sending fluid specimen to the lab should be implemented. Cloudy green fluid aspirated from a nasogastric tube (NGT) can indicate that the tube is in the wrong place, likely in the respiratory tract (trachea) instead of the gastrointestinal tract (stomach). The green colour suggests the presence of bile, which is normally found in the stomach but not in the respiratory tract. This is a serious situation that requires immediate attention.

The most appropriate intervention in this case is to send the fluid specimen to the lab for analysis. This is important for confirmation of the content and to guide further steps. The nurse should also consult the healthcare provider to determine the appropriate course of action, which might involve removing and reinserting the NGT correctly.

Choice B

Withdrawing the NGT and reinsert should not be implemented. If the NGT is in the wrong place, reinserting it without further assessment could worsen the situation. The nurse should not reinsert the NGT until the correct placement is confirmed.

Choice C

Connecting the NGT to wall suction should not be implemented. Connecting the NGT to wall suction without verifying its placement could cause harm, especially if the tube is in the respiratory tract.

Choice D

Determine pH value of specimen should not be implemented. While assessing the pH of aspirated fluid can help confirm the location of the NGT, sending the specimen to the lab for analysis is a more comprehensive action in this situation, as it allows for more detailed examination and guidance for appropriate next steps.

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The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who was diagnosed with hypocalcaemia, which foods should the nurse encourage the client to eat? (Select all that apply.)

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

Explanation

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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