Chapt. 5: Adult Health & Nutritional Assessment

33. A nurse practitioners assessment of a new patient includes each of the four basic assessment techniques. When using percussion, which of the following is the nurse able to assess?

A) Borders of the patients heart (Percussion allows the examiner to assess such normal anatomic details as the borders of the heart and the movement of the diaphragm during inspiration.)

18. A 30-year-old man is in the clinic for a yearly physical. He states, I found out that two of my uncles had heart attacks when they were young. This alerts the nurse to complete a genetic-specific assessment. What component should the nurse include in this assessment?

A) A complete health history, including genogram along with any history of cholesterol testing or screening and a complete physical exam (A genetic-specific exam in this case would include a complete health history, genogram, a history of cholesterol testing or screening, and a complete physical exam.)

41. A nurse who has practiced in the hospital setting for several years will now transition to a new role in the community. How does a physical assessment in the community vary in technique from physical assessment in the hospital?

A) A physical assessment in the community consists of largely the same techniques as are used in the hospital. (The physical assessment in the community and home consists of the same techniques used in the hospital, outpatient clinic, or office setting. Privacy is provided, and the person is made as comfortable as possible.)

29. The nurse is completing a family history for a patient who is admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The nurse should include questions that address which of the following health problems? Select all that apply.

A) Allergies B) Alcoholism E) Obesity (In general, the following conditions are included in a family history: cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney disease, arthritis, allergies, asthma, alcoholism, and obesity.)

You are assessing an 80-year-old patient who has presented because of an unintended weight loss of 10 pounds over the past 8 weeks. During the assessment, you learn that the patient has ill-fitting dentures and a limited intake of high-fiber foods. You would be aware that the patient is at risk for what problem?

A) Constipation (Patients with ill-fitting dentures are at a potential risk for an inadequate intake of high-fiber foods. The elderly are already at an increased risk for constipation because of other developmental factors and the potential for a decreased activity level.)

4. You are the nurse assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. You note bruising to the patients upper arm that correspond to the outline of fingers as well as yellow bruising around her left eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising?

A) Is anyone physically hurting you? (Few patients will discuss the topic of abuse unless they are directly asked. Therefore, it is important to ask direct questions, such as, Is anyone physically hurting you?)

25. A family whose religion limits the use of some forms of technology is admitting their grandfather to your unit. They express skepticism about the fact that you are recording the admission data on a laptop computer. What would be your best response to their concerns?

A) Its been found that using computers improves our patients care and reduces their health care costs. (Electronic health records are thought to improve the quality of care, reduce medical errors, and help reduce health care costs, therefore, their implementation is moving forward on a global scale.)

37. A team of community health nurses has partnered with the staff at a youth drop-in center to address some of the health promotion needs of teenagers. The nurses have identified a need to address nutritional assessment and intervention. Which of the following most often occurs during the teen years?

A) Lifelong eating habits are acquired. (Adolescence is a time of critical growth and acquisition of lifelong eating habits, and, therefore, nutritional assessment, analysis, and intervention are critical.)

6. You are taking a health history on an adult patient who is new to the clinic. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the primary significance of this information to the health history?

A) The patient may be at risk for developing diabetes. (Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics- related risk factors. The information aids the nurse in determining if the patient may be predisposed to diseases that are genetic in origin.)

5. You are the nurse performing a health assessment of an adult male patient. The man states, The doctor has already asked me all these questions. Why are you asking them all over again? What is your best response?

A) This history helps us determine what your needs may be for nursing care. (Regardless of the assessment format used, the focus of nurses during data collection is different from that of physicians and other health team members. Explaining to the patient the purpose of the nursing assessment creates a better understanding of what the nurse does. It also gives the patient an opportunity to add his or her own input into the patients care plan.)

23. You are performing the admission assessment of a patient who is being admitted to the postsurgical unit following knee arthroplasty. The patient states, Youve got more information on me now than my own family has. How do you manage to keep it all private? What is your best response to this patients concern?

A) Your information is maintained in a secure place and only those health care professionals directly involved in your care can see it. (This written record of the patients history and physical examination findings is then maintained in a secure place and made available only to those health professionals directly involved in the care of the patient.)

38. A newly admitted patient has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment. What assessment parameters are included when assessing a patients nutritional status? Select all that apply.

B) BMI C) Clinical examination findings E) Dietary data (Nutritional status includes one or more of the following methods: measurement of BMI and waist circumference, biochemical measurements, clinical examination findings, and dietary data.)

10. In your role as a school nurse, you are working with a female high school junior whose BMI is 31. When planning this girls care, you should identify what goal?

B) Increase in exercise and reduction in calorie intake (A BMI of 31 is considered clinically obese, dietary and exercise modifications would be indicated.)

2. A nurse is conducting a health assessment of an adult patient when the patient asks, Why do you need all this health information and who is going to see it? What is the nurses best response?

B) It is good you asked and you have a right to know your information helps us to provide you with the best possible care, and your records are in a secure place. (Whenever information is elicited from a person through a health history or physical examination, the person has the right to know why the information is sought and how it will be used. For this reason, it is important to explain what the history and physical examination are, how the information will be obtained, and how it will be used.)

30. The admitting nurse has just met a new patient who has been admitted from the emergency department. As the nurse introduces himself, he begins the process of inspection. What nursing action should the nurse include during this phase of assessment?

B) Pay attention to the details while observing. (It is essential to pay attention to the details in observation.)

An 89-year-old male patient is wheelchair bound following a hemorrhagic stroke and has been living in a nursing home since leaving the hospital. He returns to the adjacent primary care clinic by wheelchair for follow-up care of hypertension and other health problems. The nurse would modify his health history to include which question?

B) Tell me about where you live: Do you feel your needs are being met, and do you feel safe? (The question, Tell me about where you live: Do you feel your needs are being met and do you feel safe? seeks to explore the specific issue of the safety in the home environment.)

22. A nurse is conducting a home visit as part of the community health assessment of a patient who will receive scheduled wound care. During assessment, the nurse should prioritize which of the following variables?

B) The community and home environment, support systems or family care, and the availability of needed resources (The community or home environment, support systems or family care, and the availability of needed resources are the key factors that distinguish community assessment from assessments in the acute-care setting.)

21. A nurse who provides care in a campus medical clinic is performing an assessment of a 21-year-old student who has presented for care. After assessment, the nurse determines that the patient has a BMI of 45. What does this indicate?

B) The patient is extremely obese. (Individuals who have a BMI between 25 and 29.9 are considered overweight. Obesity is defined as a BMI of greater than 30; WHO, 2011. A BMI of 45 would indicate extreme obesity.)

34. A 51-year-old womans recent complaints of fatigue are thought to be attributable to iron-deficiency anemia. The patients subsequent diagnostic testing includes quantification of her transferrin levels. This biochemical assessment would be performed by assessing which of the following?

B) The patients serum (Biochemical assessments are made from studies of serum such as, albumin, transferrin, retinol-binding protein, electrolytes, hemoglobin, vitamin A, carotene, vitamin C, and total lymphocyte count and studies of urine such as, creatinine, thiamine, riboflavin, niacin, and iodine.)

8. A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patients statement?

B) This is an aspect of the patients religious practice. (Because this datum was obtained during a spiritual assessment, it could be that this is an aspect of the patients religious practice. It is indeed a personal choice, but this is not the primary significance of the statement.)

26. You are performing a dietary assessment with a patient who has been admitted to the medical unit with community-acquired pneumonia. The patient wants to know why the hospital needs all this information about the way he eats, asking you, Are you asking me all these questions because I am Middle Eastern? What is your best response to this patient?

B) We know that some cultural and religious practices include dietary guidelines, and we do not want to violate these. (Culture and religious practices together often determine whether certain foods are prohibited and whether certain foods and spices are eaten on certain holidays or at specific family gatherings.)

42. You are conducting an assessment of a patient in her home setting. Your patient is a 91-year-old woman who lives alone and has no family members living close by. What would you need to be aware of to aid in providing care to this patient?

B) What resources are available to the patient (The nurse must be aware of resources available in the community and methods of obtaining those resources for the patient.)

27. You are orienting a new nursing graduate to your medical unit. The new nurse has been assisting an elderly woman, who is Greek, to fill out her menu for the next day. To what resource should you refer your colleague to obtain appropriate dietary recommendations for this patient?

C) Culturally sensitive materials, such as the Mediterranean Pyramid (Culturally sensitive materials, such as the food pagoda and the Mediterranean Pyramid, are available for making appropriate dietary recommendations. MyPlate is not explicitly culturally sensitive.)

11. During your integumentary assessment of an adult female patient, you note that the patient has dry, dull, brittle hair and dry, flaky skin with poor turgor. When planning this patients nursing care, you should prioritize interventions that address what problem?

C) Deficient nutritional status (Signs of poor nutrition include dry, dull, brittle hair and dry, flaky skin with poor turgor.)

39. The segment of the population who has a BMI lower than 24 has been found to be at increased risk for poor nutritional status and its resultant problems. What else is a low BMI associated with in the community-dwelling elderly?

C) Higher mortality rate (People who have a BMI lower than 24 or who are 80% or less of their desirable body weight for height are at increased risk for problems associated with poor nutritional status. In addition, a low BMI is associated with a higher mortality rate among hospitalized patients and community-dwelling elderly.)

1. A school nurse is teaching a 14-year-old girl of normal weight some of the key factors necessary to maintain good nutrition in this stage of her growth and development. What interventions should the nurse most likely prioritize?

C) Increasing calcium intake, eating a balanced diet, and discussing eating disorders (Adolescent girls are considered to be at high risk for nutritional disorders. Increasing calcium intake and promoting a balanced diet will provide the necessary vitamins and minerals. If adolescents are diagnosed with eating disorders early, the recovery chances are increased.)

35. An older adults unexplained weight loss of 15 pounds over the past 3 months has prompted a thorough diagnostic workup. What is the nurses rationale for prioritizing biochemical assessment when appraising a persons nutritional status?

C) It reflects the tissue level of a given nutrient. (Biochemical assessment reflects both the tissue level of a given nutrient and any abnormality of metabolism in the utilization of nutrients.)

9. You are beginning your shift on a medical unit and are performing assessments appropriate to each patients diagnosis and history. When assessing a patient who has an acute staphylococcal infection, what is the most effective technique for assessing the lymph nodes of the patients neck?

C) Palpation (Palpation is a part of the assessment that allows the nurse to assess a body part through touch.)

20. In your role as a school nurse, you are performing a sports physical on a healthy adolescent girl who is planning to try out for the volleyball team. When it comes time to listen to the students heart and lungs, what is your best nursing action?

C) Perform auscultation with the diaphragm placed firmly on her skin to minimize extra noise. (Auscultation should always be performed with the diaphragm placed firmly on the skin to minimize extra noise and with the bell lightly placed on the skin to reduce distortion caused by vibration.)

24. You are admitting an elderly woman who is accompanied by her husband. The husband wants to know where the information you are obtaining is going to be kept and you follow up by describing the system of electronic health records. The husband states, I sure am not comfortable with that. It is too easy for someone to break into computer records these days. What is your best response?

C) This hospital is as concerned as you are about keeping our patients records private. So we take special precautions to make sure no one can break into our patients medical records. (Nurses must be sensitive to the needs of the older adults and others who may not be comfortable with computer technology.)

31. During a comprehensive health assessment, which of the following structures can the nurse best assess by palpation?

C) Thyroid gland (Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation. Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen and pelvis, and rectum.)

15. You are the emergency department nurse obtaining a health history from a patient who has earlier told the triage nurse that she is experiencing intermittent abdominal pain. What question should you ask to elicit the probable reason for the visit and identify her chief complaint?

C) What brings you to the hospital today? (The chief complaint should clearly address what has brought the patient to see the health care provider, an open-ended question best serves this purpose.)

14. You are teaching a nutrition education class that is being held for a group of older adults at a senior center. When planning your teaching, you should be aware that individuals at this point in the lifespan have which of the following?

D) A decreased need for calories (The older adult has a decreased metabolism, and absorption of nutrients has decreased.)

3. The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patients language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection?

D) Collect all possible data from the patient and have the family supplement missing details. (The informant, or the person providing the information, may not always be the patient. The nurse can gain information from the patient and have the family provide any missing details. The nurse should always obtain as much information as possible directly from the patient.)

36. A school nurse at a middle school is planning a health promotion initiative for girls. The nurse has identified a need for nutritional teaching. What problem is most likely to relate to nutritional problems in girls of this age?

D) Folate intake is below the recommended levels in this age group. (Adolescent girls are at particular nutritional risk, because iron, folate, and calcium intakes are below recommended levels, and they are a less physically active group compared to adolescent males.)

A home care nurse is teaching meal-planning to a patients son who is caring for his mother during her recovery from hip replacement surgery. Which of the following meals indicates that the son understands the concept of nutrition, based on the U.S. Department of Agricultures MyPlate?

D) Ham sandwich with tomato on rye bread with peaches and yogurt (This menu has a choice from each of the food groups identified in MyPlate: grains, vegetables, fruits, dairy, and protein.)

19. A patient has a newly diagnosed heart murmur. During the nurses subsequent health education, he asks if he can listen to it. What would be the nurses best response?

D) If you would like to listen to your murmur, Id be glad to help you and to show you how to use a stethoscope. (Listening with a stethoscope is auscultation and it is done with both the bell and diaphragm. The diaphragm is used to assess high-frequency sounds such as systolic heart murmurs, whereas the bell is used to assess low-frequency sounds such as diastolic heart murmurs.)

40. Imbalanced nutrition can be characterized by excessive or deficient food intake. What potential effect of imbalanced nutrition should the nurse be aware of when assessing patients?

D) Prolonging confinement to bed Malnutrition interferes with wound healing, increases susceptibility to infection, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of patients to bed.

You are the nurse caring for a patient who is Native American who arrives at the clinic for treatment related to type 2 diabetes. Which question would best provide you with information about the role of food in the patients cultural practices and identify how the patients food preferences could be related to his problem?

D) Tell me about foods that are important in your culture and how you feel they influence your diabetes. (The beliefs and practices that have been shared from generation to generation are known as cultural or ethnic patterns.)

7. A registered nurse is performing the admission assessment of a 37-year-old man who will be treated for pancreatitis on the medical unit. During the nursing assessment, the nurse asks the patient questions related to his spirituality. What is the primary rationale for this aspect of the nurses assessment?

D) The patients spiritual environment can affect his response to illness. (Illness may cause a spiritual crisis and can place considerable stresses on a persons internal resources. The term spiritual environment refers to the degree to which a person has contemplated his or her own existence.)

32. During a health assessment of an older adult with multiple chronic health problems, the nurse practitioner is utilizing multiple assessment techniques, including percussion. What is the essential principle of percussion?

D) To create vibration in a body wall (The principle of percussion is to set the chest wall or abdominal wall into vibration by striking it with a firm object.)

28. In the course of performing an admission assessment, the nurse has asked questions about the patients first-and second-order relatives. What is the primary rationale for the nurses line of questioning?

D) To identify diseases that may be genetic (To identify diseases that may be genetic, communicable, or possibly environmental in origin, the interviewer asks about the age and health status, or the age and cause of death, of first-order relatives like parents, siblings, spouse, children and second-order relatives like grandparents, cousins.)