which of the following signs or symptoms indicates a possible nutritional deiciency
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Prep

1. Which of the following signs or symptoms indicates a possible nutritional deficiency?

Correct answer: D

Rationale: A client with poor nutritional intake may have pale mucous membranes surrounding the eye, or the conjunctiva. This area should normally be pink, indicating good circulation and a lack of irritation or dryness. Improper nutrition can manifest as numerous signs in the body, including bowed legs, pale mucous membranes, a smooth or beefy tongue, and poor muscle tone. Subcutaneous fat at the waist and abdomen is not a sign of nutritional deficiency but rather of excess fat deposition. The presence of papillae on the surface of the tongue is normal and not indicative of a nutritional deficiency. Straight arms and legs are also typical anatomical features and not specifically related to nutritional deficiencies.

2. Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?

Correct answer: D

Rationale: The highest priority nursing intervention for a client at risk for falls in a hospital setting is to place the bed in the lowest position. This action ensures that the client falls the shortest distance, reducing the risk of injury. Keeping all side rails up (Option A) may lead to a fall with injury, as the client might attempt to get over the rail and fall from a higher distance. Reviewing prescribed medications (Option B) is important as certain medications can increase the risk of falling, but it is not the best answer as it is not applicable to all clients. Completing the "get up and go"? test (Option C) can help assess a client's risk for falling but does not directly prevent injury.

3. When printing out an EKG, a nurse notices that the QRS complexes are extremely small. What should be the next step?

Correct answer: C

Rationale: Increasing the sensitivity control to 20 mm deflection will double the sensitivity, allowing for better observation of the small QRS complexes. This step is crucial in obtaining a clearer EKG reading. Choice A is incorrect because small QRS complexes do not necessarily indicate impending cardiac arrest; it's more likely a technical issue. Choice B is not the first step to take when small QRS complexes are observed; it's important to adjust the settings first. Choice D is incorrect because decreasing the run speed to 50 is not the appropriate action for this situation; adjusting the sensitivity control is more relevant to improve the visualization of the complexes.

4. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?

Correct answer: C

Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.

5. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?

Correct answer: C

Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.

Similar Questions

A patient who is displaying the defense mechanism of Compensation would:
A nurse is completing an incident report about a medication error that she made when she accidentally administered too much insulin to a diabetic client. All of the following are components of this documentation EXCEPT:
When performing a physical assessment, what technique should the nurse always perform first?
In a 68-year-old man, a gradual loss of hearing is known as _____________.
The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses