When assessing a 49-year-old woman who has a nursing diagnosis of imbalanced nutrition, less than body requirements related to dysphagia, which data would the nurse expect to find?
Increased hair growth.
Sore, inflamed buccal cavity.
Adequate nutrient or food intake.
Weight within 10% of ideal body weight.
The Correct Answer is B
Choice A rationale
Increased hair growth is typically associated with hormonal imbalances, such as an excess of androgens, or certain medications, not generally with undernutrition. Adequate nutrition is essential for maintaining normal hair growth cycles. Nutritional deficiencies often lead to hair thinning or loss, rather than increased growth.
Choice B rationale
A sore, inflamed buccal cavity, also known as stomatitis or mucositis, can be a direct consequence of inadequate nutrition, particularly deficiencies in B vitamins, iron, and vitamin C. These nutrients are crucial for maintaining the health and integrity of the oral mucous membranes. Inflammation and soreness can make eating painful, further contributing to poor nutrient intake.
Choice C rationale
Adequate nutrient or food intake directly contradicts the nursing diagnosis of imbalanced nutrition, less than body requirements. This finding would indicate that the patient's nutritional needs are being met, and the diagnosis would be inaccurate. The presence of dysphagia suggests difficulty in achieving adequate intake.
Choice D rationale
A weight within 10% of ideal body weight suggests that the patient's nutritional status is likely adequate, not less than body requirements. While dysphagia can lead to weight loss, a weight within the normal range indicates that the patient has been able to maintain their weight despite potential swallowing difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Step 1: The physician ordered 10 mg per dose.
Step 2: The available tablet strength is 5 mg per tablet.
Step 3: To find the number of tablets per dose, divide the ordered dose by the tablet strength: 10 mg ÷ 5 mg/tablet = 2 tablets.
Step 4: The nurse will administer 2 tablets per dose.
Final answer: 2 tablets.
Correct Answer is A,B,C,D
Explanation
Choice A rationale
Verifying tube placement is the initial critical step to ensure the feeding is delivered into the gastrointestinal tract and not the respiratory system, thereby preventing aspiration. Methods for verification include pH testing of aspirate (target pH ≤ 5.5), and radiographic confirmation is the gold standard, especially after initial placement.
Choice B rationale
Checking the residual feeding contents before administering a new feeding is essential to assess the client's tolerance to the previous feeding and prevent overfeeding, which can lead to complications like abdominal distension, nausea, vomiting, and aspiration. A high residual volume may indicate delayed gastric emptying.
Choice C rationale
Administering the feeding follows confirmation of tube placement and assessment of residual volume. The feeding should be administered at the prescribed rate and volume, ensuring the client receives adequate nutrition and hydration. The client should be positioned with the head of the bed elevated at least 30-45 degrees during and for at least 30-60 minutes after feeding to minimize aspiration risk.
Choice D rationale
Evaluating the client's tolerance to the feeding is an ongoing process that involves monitoring for signs and symptoms such as abdominal distension, pain, nausea, vomiting, diarrhea, or aspiration. This evaluation helps determine if the feeding regimen needs adjustment in terms of rate, volume, or formula.
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