Which assessment data best indicates to the nurse that an older client is experiencing undernutrition?
1. Body mass index (BMI) of 21
2. Unintentional 3% weight loss over a month
3. Client takes no supplements or vitamins
4. Serum albumin is slightly below normal
1. Body mass index (BMI) of 21
Explanation: 1. A BMI less than 22 in the older person is predictive of undernutrition.
2. A 3% unintentional weight loss over a month does not indicate undernutrition. This is dependent on the client's original BMI. An unintentional weight loss is cause for concern, though.
3. Taking a multiple vitamin or other supplement is not directly connected to a diagnosis of undernutrition. If the client eats adequately, supplements are not needed for health and nutrition.
4. Albumin, prealbumin, and transferrin are plasma proteins. A lower serum albumin is less specific to malnutrition because it is affected by other conditions, such as liver disease, kidney conditions, and hydration status.
You might also like to view...
A client who has been undergoing treatment for chronic back pain has been considering complementary and alternative therapies to manage the pain. The nurse has assessed the client's needs and discussed the use of available methods with the client
Which client statement indicates the need for further instruction? A) "Caution is needed with alternative therapies, as they have not been tested by the FDA." B) "Chondroitin sulfate is a dietary supplement that I can get over the counter." C) "Glucosamine sulfate is a medication that must be prescribed by my physician." D) "I may have some stomach upset associated with glucosamine sulfate."
A 42-year-old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer
Which assessment finding would strongly suggest that this patient's lump is cancerous? A) Eversion of the right nipple and mobile mass B) Nonmobile mass with irregular edges C) Mobile mass that's soft and easily delineated D) Nonpalpable right axillary lymph nodes
The nurse observes two clients arguing in the day room. One client runs into the corner and huddles while the other follows and continues with verbal abuse. The nurse's most appropriate action would be to:
A) Authoritatively step between the two clients. B) Comfort the client huddled in the corner. C) Directly address both clients and ask what's going on. D) Engage the attention of the client who is still yelling and ask what is happening.
Giving an abdominal prep means you clean shave which of the following areas?
A) abdomen from the nipples down and including the pubic area B) legs C) abdomen from the nipple line down to and including the pubic area D) none of the above