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 C
Explanation
Choice A rationale
Trouble chewing foods such as meats and raw vegetables is more indicative of mechanical issues with chewing or dental problems rather than dysphagia, which primarily involves difficulty with swallowing. While chewing difficulties can sometimes coexist with dysphagia, the primary characteristic of dysphagia is impaired bolus transport from the mouth to the stomach.
Choice B rationale
Awakenings with a feeling of indigestion suggest issues related to gastric motility or acid reflux, not necessarily dysphagia. Indigestion involves discomfort in the upper abdomen, often related to the digestion of food in the stomach, whereas dysphagia is focused on the process of swallowing.
Choice C rationale
A feeling of choking after swallowing is a classic symptom of dysphagia. It indicates that food or liquid is not passing smoothly from the pharynx to the esophagus and may be entering the airway. This occurs due to impaired coordination or weakness of the muscles involved in swallowing.
Choice D rationale
Frequent burping, or eructation, is typically related to the release of excess gas from the stomach, often due to swallowed air or the breakdown of food. It is not a primary indicator of dysphagia, which is a disorder of the swallowing mechanism.
Correct Answer is D
Explanation
Choice A rationale
Securing the tube and retesting the pH in one hour is insufficient to confirm correct placement. While a pH of 3 suggests gastric placement (normal gastric pH is typically 1.5 to 3.5), it doesn't definitively rule out placement in the respiratory tract or intestines, as these can occasionally have acidic pH levels. Delaying definitive confirmation could lead to serious complications if the tube is misplaced.
Choice B rationale
Inserting the tube an additional 1-2 inches and retesting the pH is not a reliable method for confirming placement. Advancing the tube further without radiographic confirmation could increase the risk of trauma to the gastrointestinal tract or even pulmonary aspiration if the initial placement was incorrect. pH testing alone is not conclusive.
Choice C rationale
Auscultating for the "swoosh" of air while injecting air into the NG tube is an outdated and unreliable method for confirming placement. The sound can be misleading and may be heard even if the tube is incorrectly positioned in the esophagus or lungs. This method does not provide definitive proof of gastric placement and poses a risk of aspiration.
Choice D rationale
Obtaining an x-ray is the gold standard for confirming nasogastric tube placement. Radiographic imaging allows for direct visualization of the tube's trajectory and ensures that the distal tip is correctly positioned in the stomach or duodenum. This method provides the most accurate and reliable confirmation, minimizing the risk of complications such as aspiration or misadministration of feedings and medications.
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