Nutrition 17

A patient of normal weight asks the nurse for dietary guidelines for maintaining her weight. What does the nurse teach the patient?

"Consume fats containing unsaturated fatty acids."

Which information would the nurse share with a patient with diabetes about exercise?

"Exercise leads to improved glucose control."

The nurse is assessing a patient who reports joint pain during walking. Which question is most appropriate to be asked to assess the severity of pain in the patient

"How far do you walk before the pain in your legs begins?"

Which statement made by an adult patient demonstrates understanding of the nurse's healthy nutrition teaching?

"I will make sure that I eat a balanced diet and exercise regularly."

When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary unless the patient's last shot was administered within the past how many years?

10 years

What is the minimum recommended daily intake of macrominerals in the body?

100 mg

Which quantity of Vitamin C is recommended for wound healing?

1000 mcg

In a tripod stance, at what distance are crutches placed from the side of each foot?

15 cm

Which amount of zinc is recommended for wound healing?

15-30 mg

Which amount of retinol equivalents for vitamin A per day would the nurse recommend a patient to consume to support proper wound healing?

1600 to 2000 retinol equivalents per day

A pediatric nurse weighs a newborn and records the weight as 9 pounds. Considering that the newborn's weight gain is adequate, what would be the approximate weight of this baby at 5 months?

18

Which stage of the pressure injury involves partial-thickness loss of the dermis and manifests as a red-pink, open injury without slough?

2

The nurse is measuring crutches for a patient and determining the height and placement of the handgrips. Which distance would be between the crutch pad and the patient's axilla?

2 inches

Which statement is true about the different forms of exercise?

A patient who is immobilized in bed can perform isometric exercises

The nurse is conducting a health awareness program on eating disorders. Which condition is an example of an eating disorder?

Anorexia Nervosa Bullimia Nervosa

Where does the center of gravity of a pregnant woman shift?

Anterior

A senior nurse is teaching a group of nursing students to assess skin changes related to development of pressure injuries. Which information should the students keep in mind when assessing dark-skinned patients?

Blanching is not a conclusive sign in these patients. Differentiate skin color changes with reference to baseline skin tone. Use the Gaskin's Nursing Assessment of Skin Color (GNASC) tool for assessment of patients with dark skin.

Which term is used to explain the relationship of one body part to another along a horizontal or vertical line?

Body alignment

When teaching the patient about the use of canes, which information would the nurse include?

Canes are lightweight, easily movable devices made of wood or metal. They should be of a length equal to the distance between the greater trochanter and the floor. Canes should be kept on the stronger side of the body.

The removal of devitalized tissue from a wound describes which process?

Debridement

A long-term care facility encourages nurses to assess patients at risk of developing pressure injuries based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the long-term care facility using for risk assessment of pressure injury development?

Braden Scale

Which type of wound drainage is considered sanguineous?

Bright red, active bleeding

A patient on bed rest for several days attempts to walk with assistance. He becomes dizzy and nauseated. His pulse rate jumps from 85 beats per minute to 110 beats per minute. These signs and symptoms would

orthostatic hypotension

According to the Braden Scale for predicting pressure injury risk, which factor

poor nutrition

While assessing a patient who has a pressure injury, the nurse finds black wound tissue. In which stage is this pressure injury?

unstageable

A patient who is suffering from type 1 diabetes mellitus has recovered from a fractured tibia. The patient wishes to join a regular exercise program. Which advice would the nurse provide this patient?

Get a physical examination before starting the program. Wear a medical alert bracelet. Carry sugar packets or hard candy. Monitor blood glucose levels before and after exercises.

Which increase would exercise cause in the human body?

Joint mobility Cardiac output Basal Metabolic Rate

A patient with weakness of left leg muscles is using a single straight-legged cane. While walking, the patient first advances the cane on the left side followed by moving the left leg past the cane. The patient then moves the right leg past the cane. Which instruction would the nurse give the patient?

Keep the cane on the right side

How does the nurse move his or her own body while transferring a patient to a bed?

Keep the feet wide apart and bend at the knees.

The nurse is assessing the body alignment and posture of a patient. Which indicator would encompass an optimal standing posture?

Knees are in a straight line between the hips and ankles. Feet are flat on the floor and slightly apart. Spine is straight with normal curvatures.

The nurse is teaching a group of menopausal women about osteoporosis. Which factor would be a cause of osteoporosis?

Lack of exercise Decreased estrogen levels Increased resorption of bone tissue

Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility?

Lateral rotation surface

Which type of diet would the nurse provide a patient who has decreased cardiac output related to a decrease in myocardial contractility?

Low sodium Low Calorie High Protein

Which amino acid does the body not synthesize?

Lysine

Which amino acid is indispensable?

Lysine

Which blood cells are known as garbage cells

Macrophages

Which action is a principle of proper body mechanics when lifting or carrying objects?

Maintain a wide base of support

Which patient group would be at increased risk of wound dehiscence?

Malnourished Patients Obese Patients Patients with wound infections

In a supine position, which site has the least risk of a pressure injury?

Medial Knee

Which vitamin does not have antioxidant properties?

Vitamin D

The nurse is preparing a diet plan for a patient diagnosed with gluten intolerance. Which food item can be included in the diet plan?

White Rice

The nurse is planning a diet for a 2-year-old patient. Which food item should be included in the diet plan?

Whole Milk

Which environmental issue is a hindrance to activity and exercise?

Work sites reluctant in motivating employees for physical fitness regimens

A patient underwent a partial gastrectomy with the removal of parietal cells of the stomach. Which vitamin deficiency would the nurse look for in the patient?

b12

Which characteristic would be indicative of abnormal healing of a primary wound?

drainage for more than 3 days after closure

A patient follows an ovolactovegetarian diet. Which food item is consumed in this diet?

eggs

Which state is normal for balanced muscle tension?

Muscle tone/tonus

Which food item suggested by the nurse contains significant amounts of fiber?

Oats Barley Cornmeal

Which substance is a soluble fiber?

Oats Barley Cornmeal

The nurse is teaching three-point gait to a patient whose left ankle is fractured. Which instruction is appropriate to provide to the patient?

"Advance both crutches first and then the right leg alternately."

The nurse understands that older-adult patients are at risk of osteoarthritis because of advanced age. Which question would the nurse ask related to this risk?

"Are you able to climb stairs comfortably?" "Do you have pain in your knees or back when you walk?" "Are you able to walk for 10 minutes without experiencing pain?"

Before initiating physical activity, which assessment question does the nurse ask the patient who has had a stroke?

"Are you able to move both legs?"

The nursing assistive person asks for help to transfer a patient who is 125 pounds (56.8 kg) from the bed to a wheelchair. The patient is unable to assist. Which response by the nurse is best?

"Call the lift team for additional assistance."

Which statement made by the patient about crutch safety requires further teaching by the nurse?

"Lean on the crutches to support my body weight."

The patient with a right leg injury asks the nurse how to use a cane while ambulating. Which instruction does the nurse provide the patient?

"Place the cane forward, and keep body weight on both legs."

A patient is discharged from acute care to pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD). The patient states, "I'm afraid to go to pulmonary rehabilitation." Which statement is the nurse's best response?

"Pulmonary rehabilitation provides a safe environment for monitoring your progress."

For which duration would a patient contract the biceps and triceps muscles while performing isometric exercises?

10 seconds

Which statement made by the student nurse indicates that he or she has understood the mechanism of balance in the human body?

"The cerebellum coordinates all voluntary movements."

A patient is learning crutch walking. Before starting to walk, the patient assumes a tripod position, extends the head and neck, straightens the vertebral column, extends the hips, and flexes the knees. Which instruction would the nurse provide the patient?

"The vertebral column is in a correct position." "Keep the head and neck in an erect position." "Keep the hips in an extended position while crutch walking."

Which developmental factor related to activity and exercise would the nurse explain to the parent of a toddler?

"Toddlers have slightly everted feet." "Toddlers have a slight swayback and a protruded abdomen."

Which information would the nurse share with a patient about safe axillary crutch walking?

"Use rubber crutch tips to increase surface friction."

Which stage of pressure injury can be dressed with a transparent or hydrocolloid dressing?

1

How much volume of drainage would equal 1 g of dressing

1 mL

Which amount of protein per kilogram of body weight a day would the nurse recommend a patient consume to support wound healing?

1.25 to 1.5 g

Which patient's crutch movement is similar to the arm motion of normal walking?

Patient C

Which minimum patient weight requires the use of friction-reducing devices and at least three caregivers to handle and position the patient?

200 Pounds

Which minimum patient weight requires the use of friction-reducing devices and at least three caregivers to handle and position the patient?

200 pounds

The US Food and Drug Administration (FDA) created daily values for food labels. These daily values are based on percentages of a diet consisting of how many kilocalories per day?

2000

Exercise lowers blood glucose levels. For at least how many hours would the effect of exercise last on blood glucose levels?

24 hours

A toddler has awkward posture because of a slight swayback and protruding abdomen. The legs and feet are far apart, and the feet are slightly everted. By which age would the child become slimmer, taller, and better balanced?

3 Years

The nurse measures the distance between the greater trochanter muscle of the patient and the floor and finds it to be 3 feet. Which length in feet would be the patient's cane?

3 feet

If a patient with crutches is in a perfect tripod position, which distance in centimeters would be between the crutches?

30 cm

How many kilocalories per kilogram per day would the nurse suggest a patient consume to promote proper wound healing?

30 to 35

Which amount of fluids per kilogram per day would the nurse encourage the patient to drink for proper wound healing

30-35 mL

Which size syringe is used for irrigating an open wound

35 mL

A patient is fully dependent, and the nurse is trying to determine if an assistive device should be used. How much of the patient's weight is the nurse required to lift to validate using an assistive device?

35 pounds

How much energy does 1 g of carbohydrate produce?

4 kcal

The weight of an infant is 8 kg. If the infant needs an energy intake of 100 kcal/kg of body weight per day, what should be the total energy intake of the infant per day?

800

Which vitamin is fat-soluble and is stored in the adipose tissue of the body?

A D E

A patient is diagnosed with complete obstruction of the bile duct caused by a gallstone. The patient passes fats in the stool because of indigestion of fats. Which vitamin deficiency is the patient at risk of?

A D E K

Which term describes the suggested intake for individuals based on experimentally determined estimates of nutrient intakes?

Adequate Intake

Which gait would be correct when a patient is ascending stairs on crutches?

A modified three-point gait in which he unaffected leg is advanced between the crutches to the stairs

Which nursing intervention would the nurse provide to a patient who has impaired gas exchange related to decreased cardiac output?

Administer oxygen at 2 L/min via the nasal cannula.

Which developmental or environmental factor significantly influences the activity and exercise regimen to be followed by a patient?

Age Ethnic origin Work culture

To digest starch, which enzyme does the pancreas secrete?

Amylase

The nurse plans to provide education to the parents of school-age children. Which option would the nurse include to emphasize the results of children being less physically active outside of school?

An increase in obesity

Which term describes both selenium and betacarotene?

Antioxidants

A patient who has an acute wound because of trauma is admitted to the emergency unit. Which nursing action for wound care is the

Applying a sterile dressing as per the health care provider's prescription

How is the body alignment and posture of a patient in a standing position different from the body alignment and posture of a patient in a sitting position?

Arms hang at the sides

Which phrase best explains the term propricoception

Awareness of the position of the body and its parts

Which term is used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part?

Bedsore Pressure Sore Pressure Ulcer Decubitus Ulcer

Which measure would a nurse least likely take to prevent self-injuries from lifting patients?

Bend at the knees and keep the feet close together.

Which action occurs during the process of flexion at the elbow joint?

Biceps brachii acts as a synergistic muscle and contracts.

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated?

Blanchable erythema

When repositioning an immobile patient, the nurse notices redness over a bony prominence. Which condition is indicated when a reddened area blanches on fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

Which term refers to the process in which biochemical substances break down into simpler substances during physiological states of negative nitrogen balance?

Catabolism

The nurse is preparing a diet plan for a patient admitted to a wound care unit. After the nurse explains the diet plan to the patient, the patient asks the reason for an increase in the intake of citrus fruits. Which information would the nurse share with the patient?

Citrus fruits have antioxidant properties. These fruits help in collagen synthesis. Citrus provides fuel for cell energy.

When cleaning a wound, which action is incorrect?

Cleaning from the surrounding skin to the site of incision

Which statement is true regarding the hemostasis phase of blood clotting?

Clots form a fibrin matrix. Blood vessels constrict, and platelets gather. Blood loss is controlled, establishing bacterial control.

After surgery, the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention would the nurse do first?

Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.

Which substance is a monosaccharide?

Dextrose

The nurse is caring for older-adult patients in a nursing home. The nurse understands that older adults are susceptible to development of pressure injuries and other wounds. Which factor makes older adults more vulnerable to developing pressure injuries?

Diminished inflammatory response Loss of collagen and thinning of muscles

A patient with a body mass index (BMI) of 36 has a sedentary job and has been advised to reduce her weight. The patient states that she has never exercised. Which action would the nurse advise the patient to perform to promote reduction of weight?

Discuss her diet with a dietitian. Have realistic goals such as losing 4 pounds over 2 weeks.

The nurse is transferring a patient from the hospital bed to a stretcher. The patient responds to reflexes and is physically sound enough to assist in the transfer. Which nursing action would be a part of the transfer activity?

Dividing balanced activity between the arms and legs. Telling the patient to keep the body in proper alignment. Standing with feet wide enough apart to improve the base of stability.

When caring for a patient who can assist with positioning, which criterion would the nurse keep in mind?

Dividing the balancing activity between the arms and legs will reduce the risk of back injury.

Of which advantage would a moist application be in wound healing?

Does not promote sweating

A drug-nutrient interaction between aspirin and sodium bicarbonate would cause a decrease in the absorption of which nutrient?

Folic acid

Which bed height is a safe level used to transfer and handle patients?

Elbow

Which event describes an impulse that is transmitted from the nervous system to the musculoskeletal system?

Electrochemical activity

The nurse works at a weight loss clinic. A teenage girl approaches the nurse for advice on weight loss. Which instruction would the nurse give to the teenager to help reduce her weight?

Engage in regular exercise. Participate in outdoor sports. Include physical activities in daily routine. Avoid excessive consumption of junk foods.

The nurse is educating a patient with a history of coronary heart disease and chronic obstructive pulmonary disease (COPD) on the benefits of exercise. Which point regarding exercise does the nurse keep in mind when educating the patient?

Exercise helps in preventing recurrence of coronary heart disease.

A patient is in a tripod position. Which body part would be in alignment?

Extended hips and knees

Which measure would the nurse adopt to reposition a patient in bed?

For patients with stage III or IV pressure ulcers, care should be taken to avoid shearing force.

Upon assessing a patient, the nurse suspects anorexia nervosa. Which behavioral finding may have led the nurse to this suspicion?

Fear of becoming fat despite being significantly underweight

Which statement is true regarding sutures?

Fine sutures cause minimal tissue injury

In renal failure, protein intake should be approximately 1 to 1.4 g/kg of body weight. Which food item is the best source of this protein?

Fish

A dietitian advised the mother of a school-age child to include complete proteins in the child's diet to promote growth. Which food item would the nurse instruct the mother to include in the diet?

Fish Cheese Soybeans

Which measurement length is appropriate in determining the correct size of the cane?

Greater trochanter to the floor

Which nursing intervention would the nurse provide to a patient who is diagnosed with activity intolerance related to physical deconditioning?

Guide the patient to take a 2- to 3-mile brisk walk and perform isometric exercises 3 to 4 times a week.

Indispensable amino acids are not synthesized by the body and need to be provided by the diet. Which amino acid should be included in the diet to prevent deficiency?

Histidine Lysine Phenylalaline

A patient reports dizziness, light-headedness, and nausea. The nursing diagnosis is orthostatic hypotension. The nurse would take precautions to prevent orthostatic hypotension when changing the body from which position?

Horizontal to Vertical

Damage to any part of the central nervous system that regulates voluntary movements would cause which condition?

Impaired body alignment Impaired mobility

How does exercise affect the pulmonary system?

Increased respiratory rate and depth followed by a quicker return to the resting state

Which function describes the role of the hormone cholecystokinin?

Inhibiting the secretion of gastrin

Which action would the nurse perform during the assessment phase when caring for a patient diagnosed with impaired physical mobility?

Inspect the patient's body alignment, posture, and mobility. Observe the response of the patient's body systems to activity and exercise.

Which statement is true regarding exercise and activity?

Isometric exercises involve tensing muscles without moving body parts.

The exercise regimen of an athlete includes walking at 5:00 AM. Which exercise type is the athlete performing?

Isotonic

A patient is admitted with a stage 2 pressure injury. Which characteristic of a pressure injury is the nurse likely to find during a wound assessment?

It has a reddish-pink wound bed without slough.

Which finding is characteristic of a stage 3 pressure injury?

It has full-thickness skin loss. The subcutaneous fat may be visible. Neither the bone, tendon, nor muscle is exposed.

A patient is admitted with an injury to the knee joint. The nurse notices increased mobility of the joint while assessing the range of motion (ROM). Which factor would be the reason for the increased mobility of the knee joint?

Ligament tears

Which statement made by a nurse is correct?

Ligaments connect bone to cartilage

A patient with type 1 diabetes mellitus had normal blood glucose levels before going to the gym. While performing strenuous exercise at the gym, the patient suddenly collapsed. Which factor would be the

Low blood sugar

Which physiological component of the immune system requires biotin as a vital nutrient?

Mucus

A patient with arthritis develops iron deficiency anemia. Which consumption would the nurse ask the patient about?

NSAIDs

Which element do proteins contain that make them different from carbohydrates?

Nitrogen

Which activity would the nurse delegate to assistive personnel with regard to crutch walking?

Notifying the nurse if the patient reports pain before, during, or after exercise Notifying the nurse of patient complaints of increased fatigue, dizziness, and/or light-headedness when obtaining vital signs before and after exercise Notifying the nurse of vital sign values Preparing the patient for exercise by assisting in dressing and putting on shoes

A postoperative patient refuses to eat and complains of a loss of appetite. Which intervention would the nurse perform to improve the patient's appetite?

Offer smaller and more frequent meals

Which group of patients is at most risk for severe injuries related to falls?

Older Adults

A 36-year-old man is admitted to the hospital after a motor vehicle accident. He has sustained multiple injuries to the forehead, right elbow, and left knee. An x-ray of the knee shows a hairline fracture of the left patella. When giving cold therapy to this patient, which factor would the nurse keep in mind?

Patient should be informed that a change in sensation is normal. Patient should be within the reach of the nurse call system. Position of the patient should allow him to move away from the cold source.

Which characteristic of vitamin A differentiates it from vitamin C?

Stored in the body Fat soluble vitamin

Which physiological factor would influence a patient's activity tolerance?

Pain

Which sign or symptom is present with orthostatic hypotension?

Pallor Fainting Dizziness

By which process do particles move outward from an area of greater concentration to one of lesser concentration without the help of a special carrier?

Passive Diffusion

Which stage of pressure injury is noted to have intact skin and may include changes in skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?

STAGE 1

The edges of a patient's surgical incision are approximated, and no drainage is noted. Which type of healing does this signify?

Primary intention

Which role does vitamin A play in wound healing?

Promotes wound closure

The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair?

Protein

Which substance comprises the referenced daily intakes (RDIs) that the US Food and Drug Administration (FDA) has established?

Proteins Vitamins Minerals

The nurse understands that a pregnant woman requires iron supplementation to meet nutritional requirements. Which explanation would support why additional iron is needed during pregnancy?

Provides increased maternal blood volume

Which option best motivates a patient to participate in an exercise program?

Providing information to the patient when the patient is ready to change behavior

Which component in saliva acts on cooked starch to begin converting it to maltose?

Ptyalin

Which nursing intervention would be most appropriate for a patient who has fatigue related to poor physical condition?

Reduce the number of nighttime interruptions.

Which possible effect of exercise would manifest itself in a healthy individual?

Reduced bone loss Decreased work of breathing Decreased resting heart rate

Which benefit comprises a well-designed exercise program?

Reduced bone loss and improved muscle tone Decreased fatigue and improved tolerance to stress

Which factor increases the risk of wound infection?

Reduced local tissue defenses

Which factor would render older women more susceptible to fractures?

Resorption and Osteoporosis

Identify the type of suture depicted in the image.

Retention

Which criteria does the Braden Scale evaluate?

Risk factors that place the patient at risk of pressure injury

Which defect would be considered congenital?

Scoliosis

A patient's wound drainage appears thick and yellow. Which type of drainage is this considered?

Serous

The nurse understands that a protein deficiency can adversely affect wound healing. Which parameter should be measured to determine this deficiency in the patient?

Serum Albumin Serum Transferrin Serum Prealbumin

Which condition warrants the use of cold therapy?

direct trauma

A 45-year-old patient has been put on a low-residue diet postoperatively. Which food should be avoided in the patient's diet?

Steamed vegetables

Which substance is a disaccharide?

Sucrose Lactose Maltose

A patient has come to the clinic after sustaining an abrasion. Which characteristic of this wound type would the nurse likely find upon assessment?

Superficial Considered a partial thickness wound Weepy

Which group of muscles contract to accomplish the same movement?

Synergistic Muscles

Which structure connects muscle to bone?

Tendon

Which structure is white and glistening and defined as fibrous bands of tissue that connect muscle to bone?

Tendons

Which statement is true about osteoporosis?

The cause may be hormonal imbalances or insufficient intake of nutrients. Osteoporosis is a disorder of aging and results in the reduction of bone density or mass. The bone remains biochemically normal but has difficulty maintaining integrity and support.

The nurse is attending to a patient who is bedridden after a prolonged illness. The patient has darkly pigmented skin, which makes it difficult for the nurse to detect pressure injuries. Which characteristic will alert the nurse to the possibility the patient may develop pressure injuries?

The color remains unchanged when pressure is applied. The circumscribed area of intact skin may be warm to touch. Inflammation may be detected when compared with the surrounding skin.

Which statement regarding the skin is true?

The dermis and the inner layer of the skin provide tensile strength.

A dark-skinned hospitalized patient is bedridden. While examining the patient, which characteristic will determine that the patient has developed a pressure injury?

The skin color remains unchanged on application of pressure. The localized area of the skin appears purple.

At which point would the nurse begin discharge planning for a patient?

The time the patient enters the health care system

The nurse assesses a patient's abdominal wound and finds that the wound is in the proliferative phase of healing. Which change in the wound might have led the nurse to this conclusion?

The wound is filled with granulation tissue. The wound contracts to reduce the area that requires healing. There is reepithelialization of the wound surface.

A patient with a right knee replacement is prescribed no weight bearing on the right leg. The nurse reinforces crutch walking knowing that which crutch gait is

Three Point

The patient who has a severe left leg injury needs to avoid weight bearing on the affected leg. Which crutch gait is appropriate for the patient?

Three Point

Which gait requires the patient to bear all of the weight on one foot?

Three point alternating

Which characteristic differentiates a friction injury from a shear injury?

Type of force Involvement of tissue Presentation of the injury

The nurse is transferring a patient who weighs 320 pounds (145.5 kg) from his bed to a chair. The patient has a prescription for partial weight bearing. Which technique would be the best?

Use the ceiling-mounted lift.

Which nutrient helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis?

Vitamin A

Which nutrient supports healing by promoting wound closure?

Vitamin A

Which vitamin should be provided to a patient to promote wound healing?

Vitamin A Vitamin C

Which nutrient is an antioxidant that promotes wound healing?

Vitamin C

A patient has been advised to consume more complete proteins. Which food does the nurse suggest?

soybeans

A 70-year-old patient with diabetes is advised to perform aerobic exercises. Which activity would the patient perform?

walking