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 C

Explanation

A. The client’s current symptoms—pain, significant leg edema, and swelling—are more pressing and suggest a need to evaluate the physical cause of these symptoms rather than focusing immediately on mental status.
B. Obtaining a blood alcohol level might be relevant if there is a suspicion that recent alcohol use is contributing to the client’s condition or affecting his overall health. However, the primary concern in this case is the significant edema and pain in the left leg.
C. This is the most pertinent action to take first. The client’s symptoms of severe edema and pain in one leg, along with a history of CVA and alcohol abuse, raise concerns about possible causes such as deep vein thrombosis (DVT), infection, or trauma. Inspecting the legs for signs of infection or trauma (bruising, cuts) is crucial to determine the underlying cause of the symptoms and guide appropriate treatment.

D. While excessive salt intake can contribute to fluid retention and edema, the degree of swelling described (4+ pitting edema) and the localized nature of the problem in the left leg make it less likely that dietary salt alone is the cause.

A. Circulation impaired. B. Paresthesia reported. C. Reports feeling "on fire." D. Inflammation present.

Correct Answer is B

Explanation

A. This term suggests a problem with blood flow, which could potentially cause symptoms such as numbness or tingling. However, it does not specifically address the sensation of burning. Using this term might lead to an incorrect or incomplete assessment of the client's condition.
B. Paresthesia is a term used to describe abnormal sensations in the skin, such as burning, tingling, or prickling. The client's report of a burning sensation in the hands and legs aligns well with the definition of paresthesia. Documenting it as "paresthesia reported" accurately reflects the nature of the symptoms and is a medically precise way to describe the abnormal sensory experience.
C. This documentation uses colloquial language ("on fire") to describe the client's symptoms. While it conveys the intensity of the sensation, it is not a standardized medical term and may not be as clear or useful for clinical documentation.
D. Inflammation refers to the body's response to injury or infection, which often involves redness, swelling, heat, and pain. The term "inflammation" does not specifically describe the sensation of burning reported by the client.

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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

Correct Answer is C

Explanation

A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?

Correct Answer is B

Explanation

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