Nokea
A client weighs 165 pounds (75 kg) at admission. During hospitalization, the nurse determines that the client is maintaining adequate nutritional status if the client's weight is how many pounds?
- A. 153 pounds (69.5 kg)
- B. 155 pounds (70.4 kg)
- C. 157 pounds (71.3 kg)
- D. 160 pounds (72.7 kg)
Correct Answer: D
Rationale: Adequate nutritional status is maintained if the client's weight remains within 5 pounds of the baseline (165 pounds), so 160 to 165 pounds is acceptable. Weights below 160 pounds indicate significant loss, suggesting inadequate nutrition.
You may also like to solve these questions
The nurse is caring for a client with myasthenia gravis (MG) who is 14 weeks pregnant. Which of the following does the nurse understand about MG in the pregnant client?
- A. Most women with MG tolerate labor poorly unless they are in excellent physical health.
- B. Approximately 25% to 30% of neonates born to women with MG develop neonatal myasthenia.
- C. MG usually goes into remission with younger clients and causes exacerbation in older clients.
- D. Narcotics must be used with caution due to the risk of respiratory depression in clients who are already at risk for respiratory muscle weakness.
Correct Answer: B,D
Rationale: 25-30% of neonates may develop transient myasthenia, and narcotics require caution due to respiratory risks. Labor tolerance varies, and remission isn't age-dependent.
The nurse makes a home care visit to a client diagnosed with Bell's palsy. Which statement by the client indicates a need for further teaching?
- A. I wear an eye patch at night.
- B. I am staying on a liquid diet.
- C. I wear dark glasses when I go out.
- D. I have been gently massaging my face.
Correct Answer: B
Rationale: Bell's palsy is caused by a lower motor neuron lesion of the seventh cranial nerve that may result from infection, trauma, hemorrhage, meningitis, or tumor. It is not necessary for a client diagnosed with Bell's palsy to stay on a liquid diet. The client should be encouraged to chew on the unaffected side. Wearing an eye patch at night, dark glasses for daytime outings, and gently massaging the face identify accurate statements related to the management of Bell's palsy.
The community health is conducting a health screening clinic. The nurse interprets that which client participating in the screening is the highest priority client to provide instruction to lower the risk of developing respiratory disease?
- A. A smoker who works in an acute care hospital
- B. A person who works with lawn care pesticides
- C. A person who does woodworking as a hobby for 8 years
- D. A smoker who has cracked asbestos lining on the basement pipes
Correct Answer: D
Rationale: The client who smokes and has exposure to cracked asbestos lining is at the highest risk for respiratory disease due to the combined effects of smoking and asbestos, both potent lung irritants. Smoking alone or other exposures (pesticides, woodworking) pose risks, but the dual exposure in option D is the most severe.
The nurse provides home care instructions to a client who has been diagnosed with recurrent trichomoniasis. The nurse determines the need for follow-up teaching if the client indicates she should take which action?
- A. Avoid sexual intercourse.
- B. Perform good perineal hygiene.
- C. Use the metronidazole as prescribed.
- D. Discontinue treatment during menstruation.
Correct Answer: D
Rationale: Treatment for a recurrent vaginal trichomoniasis infection continues through the menstrual period because the vagina is more alkaline during menses, and a flare-up is more likely to occur. While the infection remains active, the client should refrain from sexual intercourse or instruct her partner to wear a condom. To help break the chain of infection, the nurse directs the client to perform perineal hygiene after each voiding and each bowel movement. Metronidazole must be taken as prescribed.
The nurse is reviewing the assessment data of a client. Which finding is most important for the client to modify to lessen the risk for coronary artery disease (CAD)?
- A. Elevated triglyceride levels
- B. Elevated serum lipase levels
- C. Elevated serum testosterone level
- D. Elevated low-density lipoprotein (LDL) levels
Correct Answer: D
Rationale: Elevated LDL levels are most directly linked to CAD, as they contribute to atherosclerosis. Triglycerides are a risk factor but less predictive, lipase is unrelated to CAD, and low testosterone, not high, may influence CAD risk.