a nurse is assessing a client who has malnutrition which of the following findings should the nurse expect
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1. A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: Malnutrition can lead to a variety of physical and mental symptoms. One common manifestation of malnutrition is a decreased mental status, which includes confusion, lethargy, and cognitive impairment. Dry skin is a typical finding in malnutrition due to the lack of essential nutrients needed for skin health. Heat intolerance is not a direct consequence of malnutrition. While malnutrition can affect respiratory function, it typically leads to decreased vital capacity rather than increased. Therefore, the correct answer is decreased mental status.

2. A client is being instructed by a nurse about foods that should be included in a low-fiber diet. Which statement by the client indicates understanding?

Correct answer: D

Rationale: The correct answer is D because canned peaches are lower in fiber compared to the other options. Carrots, celery sticks, bran muffins, and oatmeal are high-fiber choices, which are not suitable for a low-fiber diet. Choosing canned peaches aligns with the requirements of a low-fiber diet.

3. Each of the following is a function of vitamin A, except one. Which is the exception?

Correct answer: C

Rationale: The correct answer is C. Maintenance of more than 200 genes is not a function of vitamin A; instead, it is a function of Vitamin D. Vitamin A plays a crucial role in the prevention of night blindness by aiding in the production of the visual pigment rhodopsin. It also supports the growth of soft tissues and bone, as well as the integrity of body openings and their linings. Choice C is incorrect because the maintenance of genes is primarily associated with Vitamin D, not Vitamin A.

4. What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?

Correct answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

5. What is a major goal for home care nurses?

Correct answer: A

Rationale: A major goal for home care nurses is restoring maximum health function. This involves helping patients achieve their highest level of health and independence, focusing on individualized care plans tailored to each patient's needs. Choice B, promoting the health of populations, is more aligned with public health nursing rather than home care nursing. Choice C, minimizing the progress of disease, is important but not as comprehensive as restoring maximum health function. Choice D, maintaining the health of populations, is more about preventive care at a population level rather than the individualized care provided by home care nurses.

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