What can the nurse surmise from this finding? Prior to measuring a client’s height and weight, the client states, “I am 5 feet 10 inches tall and weigh 160 pounds.” Upon assessment, the nurse finds the client is shorter and weighs 15 pounds more.
A. The client might have a self-image disturbance. B. The client is lying. C. The client is embarrassed about his/her weight. D. The client hasn’t been weighed or measured in a long time.
Discrepancies between the stated height and weight and the actual measurements may provide clues to the clients self-image.
Not enough information is provided to determine if the client is lying, is embarrassed about their height and weight, or has not had a height and weight assessment recently.
Discrepancies in weight may also indicate the clients lack of awareness of sudden weight change that may be due to illness.