The nurse is obtaining nutrition information from four 20-year-old female clients. All have a BM] of 20 to 23. Which client requires the most immediate follow-up?
- A. The client eats three nutritious meals a day with no snacks
- B. The client limits her intake to 2500 calories per day
- C. The client eats only fruits, vegetables, seeds, and nuts
- D. The client eats three 350-calorie meals per day
Correct Answer: D
Rationale: By limiting meals to 350 calories each, the client consumes only 1050 calories daily, insufficient for a sedentary female’s basic energy needs, requiring immediate follow-up. Three nutritious meals may suffice, 2500 calories is appropriate, and a vegetarian diet needs protein assessment but is less urgent.
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When the office nurse completes height measurement for the 72-year-old female, the client says that she lost half an inch. Which explanation by the nurse is most accurate?
- A. As we age, we lose muscle mass.'
- B. Bone loss is due to lack of exercise.'
- C. As we age, we lose knee and hip cartilage.'
- D. The vertebral column shortens with aging.'
Correct Answer: D
Rationale: Aging causes vertebral column shortening due to water and bone density loss, leading to height reduction. Muscle mass, exercise, and cartilage loss don’t primarily affect height.
The nurse is planning a health promotion program for a group of middle-aged adults. Which topic is most appropriate for the nurse to include?
- A. Methods of contraception
- B. Stress management skills
- C. Reduction of caloric intake
- D. A safe home environment
Correct Answer: B
Rationale: Stress management skills are most important for middle-aged adults facing stressors like aging, family support, and retirement planning, which contribute to stress-related diseases. Contraception is more relevant for young adults, caloric reduction is secondary, and home safety suits families or older adults.
The nurse is collecting information from the young adult client. Which psychosocial questions should the nurse ask during the admission assessment? Select all that apply.
- A. Do you have any pets?'
- B. How many hours of sleep do you get?'
- C. When was your last bowel movement?'
- D. How much alcohol do you drink?'
- E. Can you describe your sexual activity?'
Correct Answer: A;B;D;E
Rationale: The nurse should ask about pets (enhances mental well-being), sleep (affects coping and immunity), alcohol use (impacts health risks), and sexual activity (STI/HIV risks). Bowel movement is physiological, not psychosocial.
The 62-year-old client is diagnosed with osteoporosis. Which medication, if taken by the client, should the nurse identify as posing a secondary risk factor for the client’s osteoporosis?
- A. Baby aspirin daily for past 4 years
- B. Escitalopram 5 mg daily for past 7 months
- C. Multivitamin for many years
- D. 10-year use of budesonide nostril spray bid
Correct Answer: D
Rationale: Long-term corticosteroid use, like budesonide, is a risk factor for osteoporosis. Aspirin, escitalopram, and multivitamins (with calcium/vitamin D) do not contribute to bone loss.
The older adult client is experiencing relocation stress after being admitted to a nursing home. Which intervention is best for the nurse to implement?
- A. Ask family members to explore placing the client in another nursing home
- B. Change the client’s room every week until a compatible roommate is found
- C. Place the client’s favorite items, such as a family picture, at the client’s bedside
- D. Ask that family members avoid talking to the client about being in the nursing home
Correct Answer: C
Rationale: Familiar items like a family picture reduce relocation stress. Moving facilities, changing rooms, or avoiding discussion may increase stress.
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