The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status?

A 24 hour diet history.

Status of current appetite.

History of a recent weight loss.

Condition of hair, nails, and skin.

Answer and Explanation

The Correct Answer is D

A.   While a 24-hour diet history can provide valuable information about a person's dietary intake, it may not accurately reflect their long-term nutritional habits. Additionally, some individuals may underreport or overreport their food intake.
B.   A person's current appetite can be affected by various factors, including illness, medication, and emotional state. It may not be a reliable indicator of long-term nutritional status.
C.   While weight loss can be a sign of nutritional problems, it is not always indicative of a deficiency. Other factors, such as increased physical activity or illness, can also contribute to weight loss.
D.   The condition of hair, nails, and skin can provide valuable clues about a person's nutritional status.
For example, dry, brittle hair and nails, as well as pale or scaly skin, can be signs of nutrient deficiencies such as iron, vitamin B12, or protein deficiency. These visible signs can be more indicative of long-term nutritional deficiencies than other factors.

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Correct Answer is B

Explanation

A. Soft tissue, such as the liver or spleen, typically produces a dull sound on percussion, not a high- pitched musical sound. Soft tissue is more associated with a dullness because it is denser compared to the surrounding air or fluids.
B. Gas in the gastrointestinal tract often produces a musical or high-pitched sound on percussion, known as tympany. This sound occurs because gas is less dense than other abdominal contents and resonates with a high pitch. Tympany is the most common sound heard when percussing over the stomach and intestines.
C. An intestinal mass, depending on its size and location, may produce a dull or a combination of dull and tympanic sounds. However, it is not typically associated with a high-pitched musical sound. Percussion over an intestinal mass would likely be dull rather than musical.
D. A full bladder typically produces a dull sound on percussion, not a musical high-pitched sound. A dull sound indicates the presence of a solid or fluid-filled structure, such as a full bladder.

A. Compare the skin turgor of the client's upper and lower leg. B. Observe the specific location and appearance of the ulceration. C. Note any change in the color of the ulcer when the leg is moved. D. Measure the degree of joint range of motion in the extremity.

Correct Answer is B

Explanation

A. Skin turgor assesses skin elasticity and hydration, which is more indicative of general hydration status rather than specific types of insufficiency. While poor skin turgor might be observed in various conditions, it does not specifically differentiate between venous and arterial ulcers.
B. The location and appearance of the ulcer can provide significant clues about its etiology. Venous ulcers often appear on the lower legs, particularly around the medial malleolus (inside of the ankle), and tend to have irregular, shallow, and often wet or weepy edges.
C. Changes in color upon movement can provide insight into the type of insufficiency. For arterial ulcers, the leg may appear pale or blanched when elevated and may develop a reddish or purple color when lowered due to poor blood flow.
D. Measuring joint range of motion assesses flexibility and mobility rather than the type of ulcer. While joint mobility issues can be associated with various conditions, including those affecting the vascular system, it does not directly help in distinguishing between venous and arterial insufficiency ulcers.

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The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status?

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Naxlex Comprehensive Predictor Exams

While percussing the abdomen of an adult male client, the nurse encounters a musical high-pitched sound. Which does this finding indicate?

Correct Answer is B

Explanation

The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

Correct Answer is B

Explanation

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