Which signs would alert the nurse to possible nutritional alterations? (Select all that apply, one, some, or all.)
Diaphoresis
Edema
Muscle atrophy
Impaired wound healing
Nail growth
Correct Answer : B,C,D
A. Diaphoresis (excessive sweating) is not typically associated with nutritional alterations but may occur with other conditions like fever or anxiety.
B. Edema can be a sign of protein deficiency or fluid imbalance, indicating a nutritional problem.
C. Muscle atrophy suggests a lack of sufficient protein or calories, a clear sign of malnutrition.
D. Impaired wound healing is often linked to nutritional deficiencies, particularly in vitamins and minerals like vitamin C and zinc.
E. Nail growth is generally not used to assess nutritional status. Although poor nutrition can impact hair and nails, changes in nail growth are not as immediately indicative of nutritional problems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration, not 45 degrees.
B. Enteral feeding is typically preferred over TPN because it preserves gut integrity and reduces the risk of complications such as infections.
C. Lipid intake should generally be monitored and controlled, but greater than 2 g/kg/day is not recommended and may lead to complications such as hyperlipidemia.
D. Excessive calorie intake, particularly from carbohydrates, can increase carbon dioxide production, leading to a rise in PaCO2 levels in mechanically ventilated patients.
Correct Answer is B
Explanation
A. While physical restraints may potentially cause harm, the intention in this case is to ensure safety, so it isn't directly categorized as harm.
B. Paternalism involves making decisions for the patient without their consent, believing it's for their own good, which is what the nurse is considering by using restraints for safety.
C. Deception is not involved in this situation, as the nurse is not misrepresenting the circumstances.
D. Advocacy would involve advocating for the patient's autonomy, which may not align with using restraints without the patient's consent.
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