Which of the following patients should the nurse consider as having a higher risk for malnutrition?

A 25-year-old planning to lose 20 pounds after childbirth.

A 65-year-old who recently underwent hernia surgery (postoperative day 2).

A 70-year-old who has been fasting since midnight in preparation for a colonoscopy.

A 55-year-old who has been consuming alcohol for 35 years.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While a 25-year-old planning to lose 20 pounds after childbirth may have increased nutritional needs, they would not typically be considered at higher risk for malnutrition unless there were other factors such as inadequate diet or certain health conditions.
Choice B rationale
A 65-year-old who recently underwent hernia surgery might have temporary changes in diet or appetite related to the surgery, but would not typically be at high risk for malnutrition unless there were other ongoing issues such as poor diet, difficulty eating, or a chronic health condition.
Choice C rationale
A 70-year-old who has been fasting since midnight in preparation for a colonoscopy would not typically be at risk for malnutrition from this short-term fast. However, if they had ongoing issues with diet, appetite, or a chronic health condition, they could potentially be at risk.
Choice D rationale
A 55-year-old who has been consuming alcohol for 35 years is at higher risk for malnutrition. Alcohol can interfere with the body’s ability to absorb and use nutrients, and individuals with long-term heavy alcohol use may also have other lifestyle factors that increase their risk for malnutrition.

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Correct Answer is D

Explanation

Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale

Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.

A. Dysarthria. B. Dysesthesia. C. Dyspepsia. D. Dyspnea.

Correct Answer is C

Explanation

Choice A rationale
Dysarthria, or difficulty articulating speech, is not a symptom of GERD. GERD primarily affects the digestive system, causing symptoms such as heartburn and regurgitation.
Choice B rationale
Dysesthesia, or abnormal sensation, is not a symptom of GERD. GERD does not typically cause sensory disturbances.
Choice C rationale
This is the correct answer. Dyspepsia, or indigestion, is a common symptom of GERD. It can manifest as discomfort or pain in the stomach or chest, a feeling of fullness, or problems with belching or gas.
Choice D rationale
Dyspnea, or shortness of breath, is not a typical symptom of GERD. While severe GERD can sometimes cause respiratory symptoms due to aspiration of stomach contents or irritation of the airways, it is not a common or primary symptom.

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Which of the following patients should the nurse consider as having a higher risk for malnutrition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse doesn’t hear any gurgling while listening to bowel sounds. What should be the nurse’s next course of action?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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