Chapter 5: Adult Health and Nutritional Assessment

Which nursing measure should be considered when performing a physical examination of a client using the inspection technique?

maintain standard precautions The nurse should provide a warm room for the examination and maintain standard precautions. It is not essential for the patient's family member to be present during the physical examination. The nurse should also maintain the patient's privacy. Dimming the lighting will decrease the nurse's ability to perform an adequate inspection.

A nurse is preparing to obtain the health history of an older adult client. Which question posed by the nurse best focuses the clinical evaluation of the older adult client?

"What interferes most in your daily activities?" Obtaining the health history from an older adult client requires the nurse to use a calm and unrushed manner. The best questions asked by the nurse for this client population are the questions that focus on the client's level of functioning. Symptoms in the older adult client may be more subtle than other populations and asking the client to describe symptoms may not be the best question to focus the clinical evaluation. Asking the client how old he or she was when first diagnosed with a disease or illness, or asking how the client feels about his or her health may be questions asked during the health history exam; however, these do not best focus the clinical evaluation.

A nurse is conducting a health history with a patient and has obtained the necessary biographical information. The nurse then collects data from the patient in the following categories. Place the categories in the proper sequence for data collection.

1. Chief complaint (reason for seeking care) 2. Present health concern 3. Past health history 4. Family history 5. Review of systems After obtaining biographical data, the nurse would then collect information about the patient in the following sequence: chief complaint/reason for seeking care, present health concern or illness, past health history, family history, and finally a review of systems.

The nurse working in a culturally diverse neighborhood knows that providing culturally sensitive materials during nutritional counseling will increase client understanding of the nutritional information. What is the best way for the nurse to prepare materials for the client in order to provide culturally appropriate teaching?

Access a government-sponsored website that provides culturally appropriate food guides. Culturally sensitive materials are available for making appropriate dietary recommendations. Providing extra time for the client will not increase the likelihood that the client will adhere or understand nutritional counseling. Food records are used to determine individual eating patterns and do not take cultural preferences into consideration. Specific nutrients may need to be added on an individual and culturally acceptable basis, but only as a result of an in-depth nutritional assessment.

While collecting the client profile information, the client admits to crying everyday after working 8 hours in a factory. This finding reflects what part of the profile?

Coping stratagies Present coping strategies are included in a profile category of stress and coping responses collected during the client interview. The profile is important to the chief complaint and the client's ability to deal with healthcare issues and how a client may response to health problems.

Which question by the nurse may be used to obtain educational or occupational information?

Do you have difficulty meeting you financial commitments? Inquiring about current occupation can reveal much about a person's economic status and educational preparation. A statement such as "Tell me about your job" often elicits information about role, job tasks, and satisfaction with the position. Direct questions about past employment and career goals may be asked if the person does not provide this information. It is important to learn about a person's educational background. Asking a person what kind of educational requirements were necessary to attain his or her present job is a more sensitive approach than asking whether he or she graduated from high school.

Using the assessment technique depicted in the accompanying photo, the examiner would assess which of the following structures?

Liver There are two palpation techniques: light and deep. In light palpation, the examiner uses one hand to feel superficial contents. An examiner uses both hands for deep palpation to examine the liver or kidneys.

When assessing a client who has a draining wound, the nurse would be alert for which of the following nutritional consequences? Select all that apply.

Protein loss Electrolyte loss Mineral loss A client with a draining wound would be at risk for losses of protein, electrolytes, and minerals. Caloric and fat intakes would not necessarily be affected.

A very thin woman seeks medical care. During assessment of this client, the nurse determines the need for a nutritional assessment. Which of the following components will the nurse include in this assessment? Select all that apply.

Ratio of body weight and height Oral mucosa Thyroid gland Nutritional state is often reflected in a client's appearance. Assessment of nutritional status provides information about weight loss, malnutrition, and nutrient deficiencies. Components of the nutritional assessment include body mass index (ratio of body weight and height), biochemical assessment, and physical examination of hair, teeth, oral cavity, thyroid gland, skeletal muscles, and abdomen.

A client presents with intense back pain, rating it an "11" on the 0-to-10 scale. He is hunched over and reports that the pain is running down his legs. What information will the nurse inquire about while obtaining the history of the present health concern?

The clients activity just before the pain began The history of the present problem includes such information as the date and manner in which the problem occurred, the setting in which the problem occurred, and the manifestations of the problem. Such information will help to define the problem further and determine the client's needs.

A positive nitrogen balance indicates which condition?

Tissue growth A positive nitrogen balance exists when nitrogen intake exceeds nitrogen output and indicates tissue growth. A negative nitrogen balance exists with fever, starvation, and burn injury.

Two nursing students are role-playing a client assessment situation. One of the students is acting as the nurse, and the other student is acting as the client. The task is to focus on assessing the client's lifestyle. Which question would be most appropriate for the student acting as the nurse to ask?

What do you usually do for fun? Assessing a client's lifestyle involves questions related to behaviors such as sleep patterns, exercise, nutrition, and recreation, as well as personal habits such as smoking and the use of ilicit drugs, alcohol, and caffeine. The question about what the client does for fun reflects activities. The question about where the client lives provides information about the physical environment; the question about where the client's parents came from provides information about culture, which is also part of the environment. The question about the client's childhood provides information about the client's past life events related to health.

During a nutritional assessment, the nurse measures a woman's waist at 38.5 inches (98 cm). Based on this finding, which of the following is a priorty intervention?

educate the client about her increased risk for hypertension and diabetes A waist circumference greater than 35 inches (89 cm) for a woman indicates excess abdominal fat. Those with an increased waist circumference are at risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation. It is necessary at this time to educate the client about her risks for such health deviations.