Question

A nurse is assessing a client who experienced a 5% weight loss in the past 30 days. Which of the following findings should the nurse identify as an indication of malnutrition?

A.) Moist skin
B.) Ankle edema
C.) Hyperreflexia
D.) Dilated pupils

Answer 1

Ankle edema is a classic sign of kwashiorkor, a form of malnutrition due to protein deficiency, and should be identified as an indication of malnutrition in a patient who has experienced significant weight loss.

Step-by-step explanation:

The nurse should identify Ankle edema as an indication of malnutrition. When a client experiences significant weight loss, such as 5% within the past 30 days, it's crucial to assess for signs of malnutrition. Ankle edema is associated with kwashiorkor, a severe undernutrition syndrome caused by a lack of protein which can also present with a distended abdomen and is a classic sign of this type of protein-energy malnutrition. This is different from other potential symptoms such as moist skin, hyperreflexia, and dilated pupils, which are not direct indicators of malnutrition.