Author Question: The nurse is admitting a person to the unit and is assessing the patient's nutritional status. In ... (Read 51 times)

cnetterville · **on:** Jul 24, 2018

The nurse is admitting a person to the unit and is assessing the patient's nutritional status. In assessing the patient's nutritional status, the nurse realizes that:

a. body mass index (BMI) is the main indicator of obesity.
b. ideal body is the standard gauge for nutritional status.
c. clinical judgment is required, along with other indicators.
d. the amount of weight change is the main nutritional indicator.

Question 2

Which of the following tasks might be delegated to nursing assistive personnel (NAP)?

a. Pressure dressing to an actively bleeding wound
b. Chronic wound that needs a nonsterile moist-to-dry dressing change
c. Hydrogel dressing change
d. Wound assessment during the dressing change

medine · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

C
Use clinical judgment when evaluating muscular patients or patients with large amounts of edema or ascites, because these physiological states will lead to false overestimation of the degree of fatness. BMI alone is not a perfect predictor of overweight or obesity. You gather weight information in several ways, including usual body weight (UBW), ideal body weight (IBW), actual body weight (ABW), and BMI. A thorough nutritional assessment usually requires the collection of all of these weight measures. The magnitude and direction of weight change are more meaningful than standardized weight references when one is dealing with sick or debilitated patients.

Answer to Question 2

B
The task of applying dry and moist-to-dry dressings may sometimes be delegated to nursing assistive personnel (NAP) if the wound is chronic (see facility policy and Nurse Practice Act). Wound assessments, care of acute new wounds, and wound care requiring sterile technique cannot be delegated. The application of hydrogel dressings or pressure dressings cannot be delegated.