when assessing for criteria that signify malnutrition risk which element would most likely be included as part of the functional assessment data
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1. When assessing for criteria that signify malnutrition risk, which element would most likely be included as part of the functional assessment data?

Correct answer: D

Rationale: Generalized weakness is a key indicator of malnutrition and is often assessed as part of functional status, reflecting muscle wasting and reduced physical function. The other choices, such as severity of illness, presence of pressure sores, and localized edema, are important factors to consider in a clinical assessment but are not primarily indicative of malnutrition risk. Generalized weakness directly relates to the functional impact of malnutrition on physical performance.

2. Can a person with Celiac disease eat Poptarts that contain gluten?

Correct answer: B

Rationale: A person with Celiac disease cannot consume Poptarts that contain gluten because gluten is a protein found in wheat, barley, and rye, triggering an autoimmune response in individuals with Celiac disease and damaging their small intestine. Even small quantities of gluten can lead to this harmful response, making choices 'A' and 'C' incorrect. While gluten-free Poptarts may be suitable for individuals with Celiac disease, regular Poptarts containing gluten are not safe for consumption by them, rendering choice 'D' incorrect as well.

3. Gina, A client in prolong labor said she cannot go on anymore. The health care team decided that both the child and the mother cannot anymore endure the process. The baby is premature and has a little chance of surviving. Caesarian section is not possible because Gina already lost enough blood during labor and additional losses would tend to be fatal. The husband decided that Gina should survive and gave his consent to terminate the fetus. The principle that will be used by the health care team is:

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

4. During which phase of the therapeutic relationship should the nurse inform the patient about the termination of therapy?

Correct answer: D

Rationale: The correct answer is 'Termination'. This phase of the therapeutic relationship is when the nurse informs the patient about the conclusion of therapy. It is during this phase that the nurse and the patient review the goals and progress made and also discuss the upcoming termination. The other phases are not the appropriate times for discussing termination. 'Pre-orientation' is the phase before the nurse-patient relationship is established; 'Orientation' is when the nurse and patient get to know each other and set goals; and 'Working' is when these goals are pursued. Therefore, choices A, B, and C are incorrect.

5. Which condition is most closely associated with a high rate of gastroesophageal reflux disease?

Correct answer: A

Rationale: Pregnancy is the correct answer as it is most closely associated with a high rate of gastroesophageal reflux disease (GERD). During pregnancy, the growing fetus exerts pressure on the stomach, leading to the backflow of stomach acid into the esophagus, causing GERD. This physiological change is a common occurrence in pregnant individuals. Conversely, anorexia, hypertension, and diabetes mellitus are not typically linked to a high rate of GERD. While these conditions have their own effects on the body, they do not directly contribute to the mechanisms that cause GERD, unlike the physical changes associated with pregnancy. Therefore, choices B, C, and D are incorrect.

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