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 B
Explanation
Choice A rationale
Light palpation is typically performed after auscultation to assess for superficial tenderness, muscle tone, and pulsations. Auscultation precedes palpation to avoid inducing artificial bowel sounds or altering existing ones due to manual pressure.
Choice B rationale
Auscultation of bowel sounds in all four quadrants is the next step in the abdominal assessment after inspection. Listening to bowel sounds provides information about the motility of the gastrointestinal tract and should be done before palpation or percussion, which can alter these sounds.
Choice C rationale
Percussion for tones in all four quadrants is usually performed after auscultation and before palpation. Percussion helps to assess the size and density of abdominal organs and to identify the presence of fluid or air.
Choice D rationale
Deep palpation is performed last in the abdominal assessment sequence to evaluate for deeper masses and aortic pulsations. It follows inspection, auscultation, and light palpation, allowing the nurse to gather preliminary information before applying deeper pressure. .
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Vanilla pudding is often restricted in dysphagia diets due to its smooth, slippery texture, which can be difficult to control in the oral cavity and increases the risk of aspiration into the airway. Individuals with dysphagia may have impaired swallowing mechanisms, making thin, liquid-like consistencies particularly hazardous.
Choice B rationale
Cranberry juice is a thin liquid and poses a significant aspiration risk for a patient with dysphagia. Thin liquids are difficult to manage in the mouth and throat, increasing the likelihood of the liquid entering the trachea instead of the esophagus. Patients with swallowing difficulties often require thickened liquids to improve bolus control.
Choice C rationale
Beef broth is a clear liquid and, similar to cranberry juice, presents a high risk of aspiration for a patient with dysphagia. Its thin consistency makes it challenging for individuals with impaired swallowing to control its movement, potentially leading to it entering the airway and causing respiratory complications.
Choice D rationale
Orange gelatin, while seemingly semi-solid, often melts into a thin liquid in the mouth due to body temperature. This change in consistency makes it difficult to control and increases the risk of aspiration in patients with dysphagia. Gelatin's slippery texture further compounds this risk.
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