A nurse is caring for a client who has a body mass index (BMI) of 26. The nurse should place the client in which BMI category?
Obese
Underweight
Overweight
Healthy weight
The Correct Answer is C
A. A BMI of 26 is not classified as obese; obesity typically starts at a BMI of 30.
B. Underweight is defined as a BMI less than 18.5, which does not apply to this client.
C. A BMI of 26 falls within the overweight category, which is defined as a BMI between 25 and 29.9.
D. A healthy weight is classified as a BMI between 18.5 and 24.9, which does not include a BMI of 26.
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Correct Answer is D
Explanation
A. The severity of the condition may correlate with pain but is not a direct measure of the individual's pain experience.
B. Vital signs can change due to pain but are not specific indicators of pain intensity or presence.
C. Nonverbal behavior can provide clues about pain but is subjective and can vary greatly between individuals.
D. Self-rating of pain is considered the most reliable indicator of pain because it reflects the individual's personal experience and perception of their pain, making it the gold standard for assessing pain intensity.
Correct Answer is A
Explanation
A. To determine the heart rate from a rhythm strip, you can count the number of R-R intervals in a set time frame (typically 6 seconds) and multiply by 10 to convert to beats per minute. If the rhythm is regular, you can also use the 300 method by dividing 300 by the number of large squares between R waves. In this case, the rate is calculated to be 90 beats per minute.
B. A heart rate of 110 beats per minute would be classified as tachycardia and is not supported by the observed intervals.
C. A heart rate of 73 beats per minute would be a normal resting heart rate but does not match the calculation from the rhythm strip.
D. A heart rate of 50 beats per minute would indicate bradycardia, which is not reflected in this rhythm strip.