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
Palpating the tender area first can cause increased pain and muscle guarding, potentially interfering with the subsequent auscultation of bowel sounds. It is important to auscultate before palpation to avoid altering the natural bowel sounds.
Choice B rationale
Examining the tender area last minimizes the client's discomfort and reduces the likelihood of muscle guarding affecting the assessment of other abdominal areas. This systematic approach allows for a more accurate evaluation of non-tender regions before focusing on the area of complaint.
Choice C rationale
Examining the tender area first will likely cause the patient increased discomfort, leading to muscle guarding that can make it difficult to accurately assess other areas of the abdomen. This approach can also make the patient apprehensive and less cooperative for the remainder of the examination.
Choice D rationale
Avoiding palpation of the tender area altogether would result in an incomplete assessment. Palpation is crucial for evaluating tenderness, masses, and organomegaly in the area of the patient's pain. Modifying the order of assessment is preferred over complete avoidance.
Correct Answer is ["A","C"]
Explanation
Choice A rationale
Dried beans, including varieties like black beans, pinto beans, and navy beans, are a rich source of plant-based protein. They provide essential amino acids necessary for growth and development in toddlers following a vegetarian diet. Incorporating beans into meals helps meet their protein requirements.
Choice B rationale
Apple slices are primarily a source of carbohydrates, fiber, and some vitamins. They contain very little protein and would not be a significant contributor to increasing the protein intake of a vegetarian toddler.
Choice C rationale
Green peas are a good source of plant-based protein in addition to fiber and vitamins. They offer a higher protein content compared to many other vegetables and can be easily incorporated into a toddler's diet to help meet their protein needs on a vegetarian regimen.
Choice D rationale
Mashed potatoes are mainly a source of carbohydrates in the form of starch. While they provide energy and some nutrients, they are low in protein and not an ideal food choice for increasing dietary protein intake in a vegetarian toddler. .
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