NUR 3065 Prepu Chapter 8
An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize? Do you use any over-the-counter dietary supplements? "Are you familiar with the USDA's MyPlate recommendations?" "Have you ever been diagnosed with heart disease?" "Are you currently taking any diuretic medications?"
"Are you currently taking any diuretic medications?" Explanation: Use of diuretics creates a risk for dehydration due to excessive fluid loss. Common dietary supplements are not noted to have this effect, and heart disease is not directly associated with inadequate hydration. The client's knowledge of dietary recommendations such as MyPlate is not directly relevant to assessment for dehydration.
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?" Did you eat breakfast today? "How many meals do you eat each day?" "How often do you eat out?"
"Can you tell me what you've eaten in the last 24 hours?" Explanation: The assessment should begin with questions regarding the client's dietary habits and should elicit information about average daily food and fluid intake. A 24-hour diet recall would be the best question to gather this information. Then the nurse can gather more specific data such as meals eaten, meal pattern, and other areas such as eating out.
The nurse is preparing to perform a nutritional assessment of a newly admitted client. What question would be most appropriate for the nurse to ask when initiating the assessment? "Did you eat breakfast today?" "What have you eaten in the last 24 hours?" "How many meals do you eat each day?" "How often do you eat out?"
"What have you eaten in the last 24 hours?" Explanation: The assessment should begin with questions regarding the client's dietary habits and should elicit information about average daily food and fluid intake. A 24-hour diet recall would normally be the best question to gather this information. Then the nurse can gather more specific data such as meals eaten, meal pattern, and other areas such as eating out.
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." Explanation: Infants, children, and adolescents require different nutrients based on developmental and growth factors. For example, fat intake is crucial to brain development in infants and young toddlers. Therefore, whole milk is recommended for children younger than 2 years.
A nurse is working with a client whose ideal body weight is 130 lb. At what weight would this client first be considered overweight?
143 lb Explanation: Generally, a person who is 10% over ideal body weight (IBW) is considered overweight, whereas one who is 20% over IBW is considered obese. Ten percent of 130 would be 13; 13 + 130 = 143.
A nurse assesses a 114-pound adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client?
19 BMI Explanation: The BMI is calculated by dividing weight in pounds by height in inches squared, multiplied by 703. The body mass index calculated by the nurse should be 19 for a client who is 5 feet 5 inches tall (65 inches). Assuming the same height and different weight, such as 120 pounds, the BMI would be 20, whereas for 126 pounds the BMI would be 21, while for 132 pounds the BMI would be 22. The nurse should obtain the client's weight and height to determine body mass index, which can be calculated regardless of the client's gender.
Which of the following measurements of waist circumference would lead the nurse to suspect that a female client is at an increased risk for cardiovascular disease and diabetes? 36 inches 34 inches 32 inches 30 inches
36 inches Explanation: Women with 35 inches or greater waist circumference are at an increase risk for such disorders as diabetes, hypertension, hyperlipidemia, and cardiovascular disease.
A client is interested in losing 15 pounds, and she informs the nurse she is counting her calorie intake each day. The client has a goal of losing 1 pound a week until she reaches her goal. The client asks the nurse how many calories she should decrease daily to lose a pound a week. What is the nurse's best response?
500 calories/day Explanation: To lose 1 pound (0.45 kg) in a week, daily calorie intake should be decreased by 500 calories a day. One pound of body fat equals about 3,500 calories; 3,500 calories divided by 7 days = 500 calories/day.
A client describes probable night blindness. Intake of what vitamin should be evaluated?
A
Of the following measurements, which one helps to determine if a client is underweight, normal weight, or obese?
Body mass index. Explanation: BMI18.5 is considered underweight. BMI between 25.0 and 29.9 is considered overweight and increases risk for health problems. A BMI of 30 or greater is considered obese and places the client at a much higher risk for type 2 diabetes, cardiovascular disease, osteoarthritis, and sleep apnea.
Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease?
Females with 88.9 cm (35 in) or greater waist circumference. Explanation: Adults with large visceral fat stores located mainly around the waist (android obesity) are more likely to develop health-related problems than if the fat is located in the hips or thighs (gynoid obesity). These problems include an increased risk of type 2 diabetes, abnormal cholesterol and triglyceride levels, hypertension, and cardiovascular disease such as heart attack or stroke.
How can a nurse best assess a client's dietary habits?
Obtain a 24 hour dietary recall of all foods and fluids consumed Explanation: The nurse can best assess dietary habits by asking the client about an average daily intake of food and fluids, where and when food is consumed, and if there are any conditions or diseases that may affect intake or absorption of nutrients. A height and weight may not accurately reflect dietary intake. One meal will not provide the best assessment of overall dietary habits.
What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?
Place the tape measure behind the client and measure at the umbilicus Explanation: The nurse should place the tape measure behind the client and measure at the umbilicus. The umbilicus should be the starting point when measuring the abdomen, especially when distention is apparent. Abdominal measurement is generally taken in the morning after voiding, not after the client has had a full meal. The ideal position to measure the abdomen is standing, not sitting. The nurse informs the client that the pen mark on the abdomen should not be washed off only if the client is being monitored on a regular basis to determine progress of treatment for abdominal distention.
A client has just had abdominal surgery and the nurse is consulting with the client about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?
Protein Explanation: Complete proteins contain sufficient amounts of the essential amino acids to maintain body tissues and to promote growth.
A nurse is providing nutritional instruction at a health fair. She instructs passersby on the characteristics of a nutrient that is the body's first source of energy, sparing use of other nutrients for this purpose, that raises the blood glucose level, is found in fruit juices, and that can be converted quickly into energy. To which of the following nutrients is the nurse referring?
Simple carbohydrates Explanation: Briefly, carbohydrates are referred to as either simple or complex, depending on their chemical structure. Simple carbohydrates, such as found in fruit juice, are sugar with a simple structure that raises the blood glucose level and can be converted quickly into energy. Complex carbohydrates, such as whole grains, are starches that more slowly convert into energy and can also be used as an energy source. Carbohydrates are known as protein sparing because the body uses them for an energy source rather than breaking down proteins to fuel the body's energy needs. Protein and fat can be used as energy sources but are not the body's first source of energy, and are metabolized more slowly.
The nurse's assessment reveals that a client is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate?
Teaching the client muscle-building exercises Explanation: The MAMC decreases to the lower percentiles with malnutrition and in obesity if the TSF is high. If the MAMC is low and the TSF is high, the client may benefit from muscle-building exercise that increase muscle mass and decrease fat.
When beginning a height measurement on a 14-year-old, the nurse should instruct the client to stand on the scale with heels together.
True Explanation: If a scale is available, the nurse should instruct the client to stand shoeless on the scale with heels together and back straight, looking straight ahead. The nurses then should use the L-shaped measuring attachment on the scale to measure height.
In her assessment of a client, a nurse finds that the client has soft, spongy, and bleeding gums. The nurse recognizes that this client most likely has a deficiency in which of the following?
Vitamin C Explanation: Soft, spongy, and bleeding gums are a sign of vitamin C deficiency. Iron deficiency is associated with spoon-shaped, brittle, or rigid nails. Vitamin B12 deficiency is associated with a beefy, red tongue. Protein deficiency is associated with thinning, dry hair, edema, and ascites.
Bulimia differs from anorexia in that bulimics
crave food
Because BMI is calculated using only height and weight, the nurse knows that inaccurate findings would most likely occur in a client
who is a bodybuilder. Explanation: The use of BMI alone is not diagnostic of a client's health status. Because BMI does not differentiate between fat or muscle tissue, inaccurately high or low findings can result for people who are particularly muscular or for older adults who tend to lose muscle mass.