NCLEX-PN® ExaminationHealth Promotion and MaintenanceMedium
A practical nurse is conducting a health assessment on a 75-year-old client who lives alone and reports decreased appetite and unintentional weight loss over the past few months. The client states, 'It's just too much trouble to cook for one.' Which nursing diagnosis is most appropriate for this client?
- AChronic Pain related to aging process.
- BSocial Isolation related to living alone.
- CRisk for Falls related to muscle weakness.
- DImbalanced Nutrition: Less Than Body Requirements related to decreased interest in food preparation.
Show answer & explanationAnswer & explanation
Correct answer: D. Imbalanced Nutrition: Less Than Body Requirements related to decreased interest in food preparation.
The client's reported decreased appetite, unintentional weight loss, and statement about cooking for one directly point to an issue with nutritional intake, specifically that the intake is less than what the body needs due to barriers in food preparation.
Why the other options are wrong
- A. There is no information in the stem to suggest the client is experiencing chronic pain.
- B. While the client lives alone, social isolation is a potential contributing factor but not the primary problem identified (which is nutritional).
- C. While possible in older adults, there is no direct evidence in the stem to support muscle weakness or fall risk.
Nursing Diagnosis: Imbalanced Nutrition
A clinical judgment about an individual's actual or potential nutritional intake that is insufficient or in excess of metabolic needs.
- Less Than Body Requirements: Intake insufficient to meet metabolic needs.
- More Than Body Requirements: Intake exceeds metabolic needs.
- Related factors can include psychological, social, economic, or physical barriers.
Memory trick: Appetite's Absence Alters Aged's Aliments.