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 is: The physician ordered 40 mg of pantoprazole.
Step 2 is: The available tablets are 20 mg each.
Step 3 is: To find the number of tablets needed, divide the ordered dose by the available dose: 40 mg ÷ 20 mg/tablet.
Step 4 is: 40 ÷ 20 = 2. Final Answer: The nurse will administer 2 tablets. .
Correct Answer is C
Explanation
Choice A rationale
Listening for bowel sounds for only 1 minute in one area is insufficient to determine their presence or absence accurately. Bowel motility and thus bowel sounds can be intermittent, and listening for a brief period might miss infrequent sounds. A more extended auscultation is necessary to assess bowel activity adequately.
Choice B rationale
Listening for 2 minutes in each quadrant totals 8 minutes of auscultation, which is more comprehensive than 1 minute. However, bowel sounds can still be sporadic. A longer duration of listening in at least one quadrant where sounds might be present is needed before concluding they are absent.
Choice C rationale
Auscultating for bowel sounds for a total of 5 minutes (not necessarily 5 minutes in each quadrant, but listening attentively in different areas for a cumulative of 5 minutes) is the generally accepted minimum duration to confidently declare bowel sounds absent, termed "silent bowel sounds.”. This extended listening time increases the likelihood of detecting any intermittent bowel activity.
Choice D rationale
Listening for 10 minutes is even more thorough, but if no bowel sounds are heard after a continuous and attentive 5-minute auscultation, it is generally considered clinically significant for absent bowel sounds. Prolonged auscultation beyond 5 minutes is usually not necessary unless there are specific clinical indications.
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