The practical nurse (PN) is doing a focused assessment for a young adult client. Which information provides the best indication of the individual's nutritional status?

Status of current appetite.

A 24 hour diet history.

Condition of hair, nails, and skin.

History of a recent weight loss.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Status of current appetite: While appetite provides insight into recent food intake and potential acute changes, it is a subjective and short-term indicator. Appetite alone does not accurately reflect overall nutritional status or the presence of chronic deficiencies.

B. A 24 hour diet history: A 24-hour recall offers a snapshot of recent dietary intake but may not represent typical eating patterns. It also may be influenced by recall bias, making it insufficient as a standalone measure of nutritional status.

C. Condition of hair, nails, and skin: Physical examination of hair, nails, and skin provides objective evidence of long-term nutritional status. Signs such as brittle nails, hair thinning, or dry, scaly skin can indicate deficiencies in protein, vitamins, or minerals, making these findings reliable indicators of overall nutrition.

D. History of a recent weight loss: Recent weight loss can signal malnutrition or illness but does not provide detailed information about nutrient intake or deficiencies. It must be considered alongside physical signs and dietary history to fully evaluate nutritional status.

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Correct Answer is A

Explanation

Rationale:

A. Pleural friction rub: A pleural friction rub is a low-pitched, dry, grating sound heard during both inspiration and expiration. It occurs when inflamed pleural surfaces rub together and is usually not cleared by coughing. It often indicates pleuritis or other conditions causing pleural inflammation and may be associated with pain during deep breaths.

B. Wheezing: Wheezing is a high-pitched, musical sound usually heard during expiration and sometimes inspiration, caused by narrowed airways due to bronchospasm, inflammation, or obstruction. It differs from a pleural friction rub in pitch, timing, and origin, and is often associated with asthma or COPD.

C. Coarse rhonchi: Coarse rhonchi are low-pitched, rattling lung sounds caused by secretions in larger airways. They may change or clear with coughing, unlike pleural friction rubs, which are persistent and unaffected by coughing.

D. Stridor: Stridor is a harsh, high-pitched sound heard primarily during inspiration and is caused by upper airway obstruction. It is distinct from a pleural friction rub in both location and mechanism, indicating obstruction rather than pleural inflammation.

A. Assess level of consciousness. B. Obtain a doppler stethoscope. C. Measure the blood pressure. D. Elevate both feet on a pillow.

Correct Answer is B

Explanation

Rationale:

A. Assess level of consciousness: Level of consciousness provides information about neurologic status but does not directly address absent peripheral pulses. While important in overall assessment, it does not help determine the presence or adequacy of blood flow to the extremity.

B. Obtain a doppler stethoscope: Using a Doppler device allows the PN to detect blood flow when a pulse is not palpable by touch. This is a standard follow-up action for assessing peripheral perfusion, particularly in older adults or clients with edema, obesity, or vascular disease that can make palpation difficult.

C. Measure the blood pressure: Blood pressure measurement provides systemic perfusion data but does not identify localized arterial flow to a specific extremity. A normal blood pressure does not rule out peripheral vascular compromise in the foot.

D. Elevate both feet on a pillow: Elevating the extremities may improve venous return but does not aid in locating or confirming an absent dorsalis pedis pulse. This is not effective for evaluating arterial perfusion at the site of concern.

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The practical nurse (PN) is doing a focused assessment for a young adult client. Which information provides the best indication of the individual's nutritional status?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is auscultating the lung fields of a client exhibiting a low-pitched, grating sound during inspiration and expiration. The PN notes that coughing does not clear the sound. Which term best describes this lung sound?

Correct Answer is A

Explanation

When checking a client's peripheral pulses, the practical nurse (PN) is unable to palpate the dorsalis pedis pulse. Which follow- up action should the PN take?

Correct Answer is B

Explanation

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