Assessment exam 2

You are doing a dietary assessment with your new patient. The patient asks you why the hospital wants to know all this information about the way they eat. They specifically ask you "Are you asking all these questions because I am Middle Eastern?" What would be the most correct response you could give this patient?

"We know that culture and religious practices often determine dietary prohibitions and we do not want to offend any of our patients."

The nurse is conducting a nutrition history with a young adult with signs and symptoms of an eating disorder. Which question exemplifies the most effective way for the nurse to ask about body image?

"What would you change about your body, if you could?"

To calculate the ideal body weight for a woman, the nurse allows

100 pounds for 5 feet of height. Explanation:, p. 150.

A nurse is calculating the ideal body weight for a female client who 5 feet 5 inches and has a medium body frame. Which of the following is this client's ideal body weight?

125

A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this patient's ideal weight?

145 lb

A nurse assesses a 105-pound adult client who is 5 feet 8 inches tall. What is the estimated body mass index (BMI) for this client?

16

Which of the following scores on the Braden Scale signifies that the patient is not at risk for a pressure sore?

19 to 23

The nurse caring for a hosptalized client suspects inadequate food intake. The dietician is consulted to conduct a calorie count. How should the nurse document the client's breakfast intake?

2 slices of bacon eaten

A nurse is helping an active 48-year-old male determine his dietary needs. Which of the following would be his estimated calorie needs per day?

2,800-3,000

The nurse performs a Mini-Mental Status Examination of a client with altered thought processes. Which total score would indicate cognitive impairment?

20

An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following?

28

An individual is considered obese when his or her BMI is:

30-39

A waist circumference of greater that which of the following is indicative of excess abdominal fat in men?

40

When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet?

5

A patient describes probable night blindness. Intake of what vitamin should be evaluated?

A Explanation: p. 160.

After completing a shift assessment on clients, the nurse reviews the early morning laboratory results. One of the clients has a potassium level of 3.0. The nurse knows that this potassium level can cause what?

Fatal cardiac dysrhythmias Explanation:p. 138.

A nurse working at a health clinic performs nutritional assessments on a variety of clients in one day. Which of the following clients would be at increased risk for malnutrition? Select all that apply.

A single mother of three who makes $20,000 per year A 33-year-old smoker who says that food has lost its taste An elderly woman with Alzheimer's disease A 12-year-old girl with Crohn's disease

A nursing instructor is discussing mental health assessments with students. In what situations would the instructor tell the students an acute mental health assessment is necessary?

A situation that involves danger of harm to self or others

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested?

Abstract reasoning.p. 198.

A nurse is providing nutritional instruction to a client with cardiovascular disease. The nurse mentions a nutrient that is a necessary component of bile salts (which aid in digestion), serves as an essential element in all cell membranes, is found in brain and nerve tissue, and is essential for the production of several hormones such as estrogen, testosterone, and cortisone. The nurse warns the client, however, that this nutrient when consumed in excess can lead to heart attacks and strokes. To which of the following nutrients is the nurse referring?

Cholesterol

A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply.

Diabetes Hypertension Sleep apnea Explanation: p. 138.

The nurse conducts an assessment of an older adult. Which of the following findings indicates the client is at risk for malnutrition? (Select all that apply.)

Difficulty ambulating Ill-fitting dentures Confusion p. 139.

The nurse is admitting a patient to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?

Do you have any thoughts of wanting to harm or kill yourself?

A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. The nurse has lowered the client's arm and observed how long it takes for venous filling, then raised the same arm and watched how long it takes to empty. After determining that venous filling and emptying each take approximately 10 seconds, the nurse should perform further assessments related to what health problem?

Fluid volume deficit

A nurse is working with a client who is Buddhist. Based on what the nurse knows of the common dietary practice of this religion, which nutrient should the nurse make sure that the client is not deficient in?

Iron Explanation: p. 140.

A client with a body mass index of 28 tells the nurse she is concerned about her risk for hypertension. What can the nurse recommend to this patient?

Reducing her weight by 5% can lower her risk

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

Sebum production

Which of the following statements most accurately conveys an aspect of the anatomy and physiology of the skin?

The skin is composed of an epidermis, dermis, and subcutaneous tissue.

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

Tinea corporis p. 270.

A nurse is providing care for a patient who has a history of alcoholism. What would be appropriate to include in this patient's discharge teaching?

To increase fruit and vegetable intake

A 34-year-old woman who is conscientious about fostering and maintaining her health has brought up the question of trans fats after hearing a great deal about the subject in recent media reports. Which of the following statements from the nurse about trans fats is most accurate?

Trans fats are associated with an increased risk for cardiovascular disease.

A nurse implements which skin assessment to determine the presence of dehydration in a client?

Turgor

Which vitamin is found only in animal foods?

Vitamin B12

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.

pressure that impairs capillary blood flow to the skin friction created by dragging the skin against bedlinen shearing that occurs when sliding down in bed moisture being allowed to accumulate on the skin

The nurse is preparing to perform a nutritional assessment for a client. Which of the following questions would be most appropriate to use when initiating the assessment?

"Can you tell me what you've eaten in the last 24 hours?"

During a new client's nutritional assessment, the nurse asks the client's height and usual weight. The client states that he has no idea how much he weighs. How should the nurse respond?

"Do you feel like your weight has increased, decreased, or stayed the same lately?"

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask?

"Do you take steroid medications on a regular basis?"

Parents of a 15 month old state they are worried about the rolls of fat on the toddler's thighs; so they have switched him over to skim milk. What is the nurse's best response?

"Whole milk is recommended until age 2."

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate?

The elderly should bathe or shower only every 2 to 3 days

The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment?

The exam can provide clues about the validity of the client's responses now and throughout. Explanation:p. 194.

An older adult client has a body mass index of 15.5 and is consequently considered to be underweight. The client lives alone and states that she has "never been a heavy eater." How can the nurse most accurately assess the client's nutritional habits?

Elicit the client's 24-hour food recall.

The nurse is caring for a woman in the prenatal clinic who comments that she just cannot seem to get things "right" anymore at home and that her husband says she knows so little about life. Which type of abusive or controlling behavior is the woman describing?

Emotional abuse

Recommended protective measures to avoid skin cancer include which of the following?

Avoiding sun exposure

The patient states, "I don't know why God as abandoned me; I am a good person." Which tool would be most appropriate for the nurse to administer?

HOPE

A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status?

Brittle hair Explanation:p. 144.

Which of the following are causes of weight loss? (Mark all that apply.)

Chronic renal failure Chronic infections Adrenal insufficiency

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?

Cushing's disease

The nurse should prioritize assessments related to overhydration for a client experiencing which of the following health problems?

Early congestive heart failure

The nurse is preparing to examine a client's skin. What would the nurse do next?

Expose only the body part that is being examined.

A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states her appetite has been low for the past 3 months with a 20 pound weight loss. Which nursing diagnosis should the nurse confirm based on this data?

Imbalanced Nutrition Explanation:p. 155.

A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. Which of the following would the nurse need to keep in mind about malnutrition if the client has no reaction?

It indicates immunosuppression resulting from undernourishment.

After teaching a group of students about changes in body weight due to aging, the instructor determines that the students have understood the teaching when they state which of the following

Loss of muscle tissue contributes to the decrease in weight. Explanation:p. 148.

An older male with a history of consuming an increased amount of processed foods since the death of his wife is complaining of heart palpitations. Which lab result is priority for the nurse to assess?

Potassium level Explanation:, p. 138.

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

Psoriasis

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

Psoriasis, fungal infections, trauma

A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse?

Psychological

Which of the following would be most important for a nurse to keep in mind when assessing a client for possible physical abuse?

The abuse may start any time during a relationship.

A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking?

Skinfold thickness

A client suffering from decreased muscle strength has been diagnosed with a low Vitamin D level. The nurse should recommend that the client increase intake of which vitamin source?

Sunshine

A nurse is conducting a comprehensive nutritional assessment on a patient with suspected malnutrition. Why would it be important to assess this patient's ability to cook?

To assess if the patient has the ability to obtain or prepare food

During a physical assessment, a client reports he has had an inflamed sore on his arm for 2 weeks with no signs of healing. The nurse notes the client also has bleeding gums. What do these findings suggest regarding the client's nutritional status?

Vitamin C deficiency

Which measurement should the nurse add to the body mass index to increase the predictive ability for the client?

Waist circumference

What is the most common measurement used to determine abdominal visceral fat?

Waist circumference. Explanation:, p. 149.

A client known to a health clinic arrives wearing soiled clothing with matted hair and streaks of dirt on the face and hands. What should this client's appearance suggest to the nurse?

depression

A client has a body mass index of 26.5. What teaching would be indicated for this client?

reduce caloric intake by 250-500 calories each day

Connecting the skin to underlying structures is/are the

subcutaneous tissue.

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client'S

vesicles.