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
Chicken is poultry, and a lacto-ovo vegetarian diet excludes all meat, poultry, and fish. Grilled eggplant and cheese are acceptable as they are vegetables and dairy products, respectively. However, the presence of chicken makes this choice incorrect for a lacto-ovo vegetarian.
Choice B rationale
Boiled eggs are permitted in a lacto-ovo vegetarian diet as it includes eggs and dairy. Chocolate milk is also allowed as it is a dairy product. This choice aligns with the definition of a lacto-ovo vegetarian diet, which includes dairy and eggs but excludes meat, poultry, and fish.
Choice C rationale
Oysters are shellfish, and turkey is poultry, both of which are excluded from a lacto-ovo vegetarian diet. Yogurt is a dairy product and is acceptable. The inclusion of oysters and turkey makes this choice incorrect.
Choice D rationale
Fish is not allowed in a lacto-ovo vegetarian diet. Milk is a dairy product and is acceptable. Poached eggs are also permitted. The presence of fish makes this choice incorrect.
Correct Answer is ["200"]
Explanation
Step 1 is: The total volume to be infused is 50 mL.
Step 2 is: The infusion time is 15 minutes.
Step 3 is: To find the milliliters per hour, first convert minutes to hours: 15 minutes ÷ 60 minutes/hour = 0.25 hours.
Step 4 is: Calculate the infusion rate in mL/hour: 50 mL ÷ 0.25 hours = 200 mL/hour. The nurse will infuse the drug at 200 mL per hour.
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