Chapter 13: Assessing Nutritional Status
The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding? "Waist circumference can vary over the course of the day." "Let's discuss your risk factors for heart disease." "We should review the amount of protein in your diet." "You probably have a vitamin deficiency."
"Let's discuss your risk factors for heart disease." Waist circumference is an indicator of central body fat. In men, a waist circumference greater than 40 inches (102 cm) is strongly associated with an increased risk for heart disease. High waist circumference alone cannot provide enough information about vitamin deficiency. Other signs and symptoms must be present and further assessment is warranted prior to making this statement. Protein deficiency is associated with abdominal distension and ascites, not high waist circumference. Because waist circumference is a measure of central body fat, it stays consistent over the course of the day.
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? "Do you gather around a table with other people for meals?" "How much do you exercise in one week?" "What would you change about your body, if you could?" "How many meals and snacks do you eat in one day?"
"What would you change about your body, if you could?" As per the nutrition history, the nurse should ask if there is anything that the client would like to change about his or her body in order to identify disturbance of body image. The client should be asked if he or she gathers around a table with others for meals if the nurse is asking about family dietary patterns. The client should be asked how much he or she exercises in one week if the nurse is asking about exercise patterns. The client should be asked how many meals and snacks he or she eats in one day if the nurse is trying to determine a food pattern.
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? "How much do you exercise in one week?" "What would you change about your body, if you could?" "Do you gather around a table with other people for meals?" "How many meals and snacks do you eat in one day?"
"What would you change about your body, if you could?" As per the nutrition history, the nurse should ask if there is anything that the client would like to change about his or her body in order to identify disturbance of body image. The client should be asked if he or she gathers around a table with others for meals if the nurse is asking about family dietary patterns. The client should be asked how much he or she exercises in one week if the nurse is asking about exercise patterns. The client should be asked how many meals and snacks he or she eats in one day if the nurse is trying to determine a food pattern.
A female client with a diagnosis of hypothyroidism asks the nurse why she has begun to gain body weight. Which is the best explanation the nurse can provide? "You could be making healthier food choices." "Your metabolism is slowing down." "You are retaining fluid." "You should be exercising for longer periods of time."
"Your metabolism is slowing down." The pituitary gland is responsible for the release of thyroid stimulating hormone (TSH). Due to the decreased production of TSH in hypothyroidism, the metabolism slows down resulting in weight gain. Weight gain associated from hypothyroidism is not as a result of fluid retention, though this can be a secondary cause for additional weight gain. Although making healthy food choices and encouraging exercise are important to discuss with any client, these responses do not sufficiently explain this phenomenon.
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 client's ideal weight? 135 lb 145 lb 130 lb 140 lb
145 A general guideline, often called the rule-of-thumb method, determines ideal weight based on height. This formula is as follows: For adult females: 100 lb (for height of 5 ft) + 5 lb for each additional inch over 5 ft For adult males: 106 lb (for height of 5 ft) + 6 lb for each additional inch over 5 ft.
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? 18 16 20 22
16 The BMI is calculated by dividing weight in pounds by height in inches squared and then multiplying by 703. The body mass index calculated by the nurse should be 16 for a client who is 5 feet 8 inches tall and 105 pounds.
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? 22 BMI 21 BMI 19 BMI 20 BMI
19 BMI 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.
A nurse assesses a 350-pound adult client who is 6 feet 1 inch tall. What is the estimated body mass index (BMI) for this client? 34 46 52 29
46--The BMI is calculated by dividing weight in pounds by height in inches squared and then multiplying by 703. The body mass index calculated by the nurse should be approximately 46 for a client who is 6 feet 1 inch (73 inches) tall and 350 pounds. (less)
A client describes probable night blindness. Intake of what vitamin should be evaluated? C B A D
A
During an assessment the nurse suspects that a client has a vitamin C deficiency. What information did the nurse use to make this clinical determination? bone pain bleeding gums paresthesias dry flaky skin
A manifestation of vitamin C deficiency are bleeding gums. Bone pain is associated with a vitamin D deficiency. Paresthesias are associated with vitamin B12, pyridoxine, or thiamine deficiency. Dry flaky skin is associated with a vitamin A, vitamin B-complex, or linoleic acid deficiency.
A waist circumference of greater that which of the following is indicative of excess abdominal fat in men? 40 30 25 35
A waist circumference greater than 40 inches for men or 35 inches for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation.
The nurse conducting a nutritional assessment should notify the healthcare provider of a possible eating disorder based on which finding? Increased upper arm muscle mass Absence of menstrual periods Increased subcutaneous fat in abdomen Increased albumin level
Absence of menstrual periods Amenorrhea is a cardinal symptom of eating disorders. Lack of subcutaneous fat with prominent bones, abdominal ascites, and pitting edema are abnormal findings. Reduced albumin level is a sign of cachexia, a highly metabolic state that with accelerated muscle loss that differs from anorexia nervosa.
A nurse needs to record the height of a client who refuses to stand because of blisters on the feet. What alternative method should the nurse implement to obtain the client's height? Obtain this information subjectively from the client Provide support or hold the client to record the height Use a standard chart for height by age and gender Measure the arm span to estimate height
As the client is unable to stand, the nurse should measure arm spam to estimate the height. The nurse may support or hold the client only when the client is required to stand when recording the height. The nurse should have the client stretch one arm straight out sideways to record the height and measure from the tip of the middle finger to the tip of nose and multiply by 2. The nurse should not obtain this information subjectively from the client. A standard table listing heights and weights may be used for calculating body mass index but would not be used to determine the client's height.
When would a nurse obtain a mid-arm circumference measurement? To provide percentage of body fat and muscle tissue. To screen for nutritional excess or deficits. To assist in determining body mass index. To confirm an abnormal albumin level.
Be prepared to help adolescent females and women of child-bearing age increase intake of iron and folic acid. Assist adults older than 50 years to identify foods rich in vitamin B12 and calcium. Advise older adults and those with dark skin or low exposure to sunlight to increase intake of vitamin D.
When would a nurse obtain a mid-arm circumference measurement? To screen for nutritional excess or deficits. To assist in determining body mass index. To provide percentage of body fat and muscle tissue. To confirm an abnormal albumin level.
Be prepared to help adolescent females and women of child-bearing age increase intake of iron and folic acid. Assist adults older than 50 years to identify foods rich in vitamin B12 and calcium. Advise older adults and those with dark skin or low exposure to sunlight to increase intake of vitamin D.
The nurse should perform which priority assessment on a client with a history of a high hydrogenated fat intake? Cardiac Skin Musculoskeletal Respiratory
Cardiac The cardiac assessment is of priority concern for this client. Foods made with hydrogenated fats are particularly harmful to the diet because they are the largest contributors of trans fats. Empirical evidence suggests that trans fats are as damaging to the heart and blood vessels as saturated fats (Mente de Koning, Shannon, and Anand, 2009).
A nurse is assessing the hydration status of a young client with a high temperature. Which interventions should the nurse implement in this case? Select all that apply. Palpate radial pulse Inspect tongue condition Check skin turgor Observe skin moisture Assess the nails
Check skin turgor Observe skin moisture Inspect tongue condition Palpate radial pulse Checking the clients skin turgor is pinching a small fold of skin, observing elasticity, and watching how quickly the skin returns to the original position. Tenting (skin does not return to original position) can indicate dehydration. Observing skin moisture helps to find abnormal and normal findings. Skin that is not excessively dry indicates a normal finding, and dry and flaky skin indicates an abnormal finding. When inspecting the tongue and furrows, the abnormal findings are dry tongue with visible papillae and several longitudinal furrows. A weak or thready pulse may indicate dehydration in a client with a high temperature. Inspecting a clients nails is done when assessing for vitamin deficiency and not when conducting hydration assessment. Abnormal nails indicate protein deficiency and are not pertinent to a hydration assessment.
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 Protein Unsaturated fat Saturated fat
Cholesterol 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.
A nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present? Single parenthood Excessive exercise Diabetes mellitus Chronic dieting
Chronic dieting, especially with fad diets, can predispose an individual to malnutrition because the amount of needed nutrients is often lacking in an effort to lose weight quickly. Single parenthood is not a risk factor for malnutrition unless the parent is unable to gain access to shopping or suffers form a lower socioeconomic status. Diabetes mellitus is a chronic disease, not a lifestyle behavior. Excessive exercising may lead to weight loss but not malnutrition.
A teenage client with cancer asks the nurse what hair is made of. What would be the nurse's best answer? "Hair consists mostly of cellular waste." "Hair consists mostly of inorganic matter." "Hair consists mostly of carbohydrates." "Hair consists mostly of protein."
D Body tissues such as muscles, bones, teeth, skin, and hair primarily consist of protein. This information makes carbohydrates, inorganic matter and cellular waste incorrect answers to the client's question.
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 client? Plan to reduce weight by 20% in 6 months. Structure eating so that no more than 500 calories are consumed each day. Reducing her weight by 5% can lower her risk Reduce daily calorie intake by 100 calories each day.
Even reducing weight by 5 to 10% can improve blood pressure and lipid levels reducing the risk of hypertension. A more rapid weight loss is not sustainable and may not lead to long term prevention of hypertension. This would be the case if the client consumes no more than 500 calories each day. This restricted level of caloric intake could also lead to nutritional deficiencies. A 10% weight reduction over 6 months is recommended. A 20% weight reduction over 6 months could be too severe and lead to nutritional deficiencies and regaining of lost weight, therefore, having little or no long term impact on preventing hypertension. A daily reduction of 100 calories will not meet the goal of a healthy and realistic weight loss which can compromise healthy blood pressure long term.
Which of the following clients will have an increased metabolic rate and require nutritional interventions? A retired person living in a temperate climate. A healthy young adult who works in an office. A person with a serious infection and fever. An older, sedentary adult with painful joints.
Factors that increase metabolic rate include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of some hormones. Aging, prolonged fasting, and sleep decrease metabolic rate.
Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease? Clients with a BMI of 23. Clients with a BMI of 20. Males with 88.9 cm (35 in) or greater waist circumference. Females with 88.9 cm (35 in) or greater waist circumference.
Females with 88.9 cm (35 in) or greater waist circumference. 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.
A middle aged client is admitted to the observation unit with right lower quadrant pain. The client has not kept down any food or drink for 24 hours. The client's temperature is 38.6°C orally (101.5°F). The client describes the pain as "achy with periods of sharp, stabbing sensations." What would be the most appropriate nutritional nursing diagnosis for a client with these assessment data? Pain related to an inability to tolerate food Fluid volume less than body requirements related to an inability to tolerate fluids Potential for malnutrition (deficit) related to an inability to tolerate food Deficient knowledge related to disease process
Fluid volume less than body requirements related to an inability to tolerate fluids Response Feedback: Fluid volume is generally affected faster than anything else when a client cannot keep fluids down. A knowledge deficit can only occur once a medical diagnosis is established. Pain is not a nutrition-related nursing diagnosis. Malnutrition does not occur during a hospitalization but over a long period.
A home care nurse is teaching a client's daughter meal planning for her mother who is recovering from a hip replacement surgery. Which of the following meals indicates that the daughter understands the concept of a nutritionally complete choice based upon the Food Guide Pyramid? Spaghetti and meat sauce with a salad Cheeseburger, carrot sticks and mushroom soup with crackers Chick and pepper stir fry and basmati rice Ham sandwich with tomato on rye bread with peaches and yogurt
Ham sandwich with tomato on rye bread with peaches and yogurt The menu has a choice from each of the food groups from the Food Guide Pyramid. The other selections are incomplete choices.
A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states that her appetite has been low for the past 3 months, and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this data? Knowledge deficit Fluid volume, excessive Activity intolerance Imbalanced nutrition
Imbalanced nutrition The nurse should confirm the nursing diagnosis of imbalanced nutrition because the client has the major defining characteristics of inadequate food intake and weight loss. Fluid volume, excessive cannot be confirmed because even with the excessive urination the client is losing weight and there is no major defining characteristic present. The client made no statement about activity intolerance or that the client does not have enough knowledge to manage the diabetes properly.
When teaching a nutrition class, what would you recommend for adults older than the age of 50? Increase foods rich in vitamin B6 and saturated fats Increase foods rich in vitamin B6 and vitamin D Increase foods rich in vitamin B12 and calcium Increase foods rich in vitamin E and folic acid
Increase foods rich in vitamin B12 and calcium Be prepared to help adolescent females and women of child-bearing age increase intake of iron and folic acid. Assist adults older than 50 years to identify foods rich in vitamin B12 and calcium. Advise older adults and those with dark skin or low exposure to sunlight to increase intake of vitamin D.
A nurse begins a comprehensive physical examination on a client and notes that the client has a large amount of adipose tissue around the waistline. The nurse recognizes that this client should be assessed for an increased risk of which diseases? Select all that apply. Colon cancer Liver disease Stroke Pancreatitis Hypertension Type II diabetes mellitus
Individuals with large visceral fat stores located primarily around the waist are at increased risk for type II diabetes mellitus, abnormal cholesterol and triglyceride levels, and cardiovascular diseases such as hypertension, stroke, and heart attack.
A client asks for help with determining the amount and type of foods to consume to improve nutritional intake. What should the nurse recommend that this client use? an 1800 calorie diet My Plate calorie counter Healthy People 2020
My Plate The U.S. Department of Agriculture's (USDA's) Choose My Plate is a tool to help individuals analyze their diet and set goals for a healthier diet. A calorie counter will not necessarily help the client select healthful foods. An 1800 calorie diet may be too much or insufficient to meet the client's nutritional needs. Healthy People 2020 does not provide direction as to how to improve nutritional status.
After assessing a new client, the nurse documents findings in the medical record. What is the best example of documenting normal findings? Clothing appears too large Nails are strong Oral mucosa is pink with white patches Hair is thin and appears oily
Nails are strong; is the documentation that represents a normal finding. Clothing that is too large might indicate weight loss. Thin, oily hair is not generally a normal finding, nor are white patches on the oral mucosa.
What is the use of dietary assessment data gathered from a client by a nurse? Evaluate an adequate diet Identify client outcomes Initiate social service consult Identify areas that are not of concern
Nurses use assessment information to identify client outcomes. The other options are distractors for the question.
You are the clinic nurse assessing a new client that has come in to see a physician. The assessment data that you collect reveals that the client is a 23 year-old female weighing 175 lb with a height of 5 ft 3 in. Her body mass index is 31. What would she be considered? Average weight Overweight Obese Underweight
Obese A body mass index of 31 is considered clinically obese. People who have a BMI lower than 18.5 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Those who have a BMI of 25 to 29 are considered overweight; those with a BMI of 30 to 39, obese; and those with a BMI greater than 40, extremely obese.
A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply. Hypertension Diabetes Anorexia Cirrhosis Sleep apnea
Obesity is an excessive fat in relation to lean body mass. The health risks of obesity include diabetes, hypertension, and sleep apnea. Anorexia is a disorder whereby food is self-limited or refused. Cirrhosis is a chronic disease that involves scarring of the liver and may interfere with the absorption or use of nutrients.
At what percent of weight over ideal weight is a person considered obese? 20% 40% 60% 100%
Obesity is defined as body weight 20% or more above ideal weight.
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? Fats Simple carbohydrates Proteins Complex carbohydrates
Simple carbohydrates 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.
A nurse has just determined a client's body mass index (BMI). Which measurement should the nurse add to the BMI to increase the predictive ability for health risk to the client? Mid-arm circumference Waist circumference Mid-arm muscle circumference Triceps skinfold measurement
The nurse should add waist circumference to the BMI to increase the predictive ability for health risk to the client of this measure. It helps to determine the extent of abdominal visceral fat in relation to the body fat. The mid-arm circumference helps to assess skeletal muscle mass and fat stores. The triceps skinfold helps to evaluate subcutaneous fat stores. The mid-arm circumference, along with the triceps skinfold measurement, are used in a formula to calculate the mid-arm muscle circumference, which is used to evaluate muscle reserve stores.
What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors? Ensure that the client has had a full meal before measuring the abdomen Place the tape measure behind the client and measure at the umbilicus Inform the client that the pen mark on the abdomen should not be washed off Ask the client to be seated and relaxed when taking the measurement
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.
An individual is considered obese when his or her BMI is: 30-39 Greater than 40 25-29 Less than 24
Those persons with a BMI of 30 to 39 are considered obese. Persons with a ABMI of less than 24 are risk for problems associated with poor nutritional status. A BMI of 25 to 29 are considered overweight. Those with a BMI of greater than 40 are considered extremely obese.
To calculate the ideal body weight for a woman, the nurse allows 6 pounds for each additional inch over 5 feet. 80 pounds for 5 feet of height. 106 pounds for 5 feet of height. 100 pounds for 5 feet of height.
To calculate the ideal body weight of a woman, the nurse allows 100 pounds for 5 feet of height and adds 5 pounds for each additional inch over 5 feet. The nurse allows 106 pounds for 5 feet of height in calculating the ideal body weight for a man. The nurse adds 6 pounds for each additional inch over 5 feet in calculating the ideal body weight for a man. Eighty pounds for 5 feet of height is too little.
A nurse is caring for several clients in an outpatient setting. Which of the following clients is most likely to experience a weight gain? A 42-year-old client with irritable bowel syndrome A 27-year-old woman with pneumonia A 33-year-old athlete on steroids A 39-year-old who has been in remission from cancer for 4 years
To provide percentage of body fat and muscle tissue. Measure mid-arm circumference (MAC) evaluates skeletal muscle mass and fat stores.
The nurse might expect the client admitted with dehydration to have tachycardia. False True
True. Tachycardia, a weak pulse and decreased blood pressure can indicate dehydration, while a bounding pulse and increased blood pressure may mean overhydration.
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? Fortified breads Orange juice Lentils Sunshine
Vitamin D is obtained through exposure to sunlight. Some people who are not exposed to enough sun may require dietary supplements. Folate can be found in fortified breads, lentils, and orange juice.
A nurse has just determined a client's body mass index (BMI). Which measurement should the nurse add to the BMI to increase the predictive ability for health risk to the client? Waist circumference Mid-arm muscle circumference Triceps skinfold measurement Mid-arm circumference
Waist circumference The nurse should add waist circumference to the BMI to increase the predictive ability for health risk to the client of this measure. It helps to determine the extent of abdominal visceral fat in relation to the body fat. The mid-arm circumference helps to assess skeletal muscle mass and fat stores. The triceps skinfold helps to evaluate subcutaneous fat stores. The mid-arm circumference, along with the triceps skinfold measurement, are used in a formula to calculate the mid-arm muscle circumference, which is used to evaluate muscle reserve stores.
A client has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply. cholesterol medications activity level temperature blood pressure
blood pressure cholesterol activity level
How can a nurse best assess a client's dietary habits? Obtain a 24 hour dietary recall of all foods and fluids consumed Obtain a height and weight and calculate a body mass index (BMI) Assess for the presence of any chronic disease processes Ask about how much food is eaten at an average meal
perform a focused nutritional interview The focused nutritional interview will provide more information and a more comprehensive assessment of the client's nutritional status. A 24-hour diet recall is a quick, yet limited, glimpseinto the client's diet that has limitations. Obtaining a list of client likes and dislikes may not be reflective of the client's actual diet. The food frequency questionnaire may provide more history than a 24-hour diet recall but is still limited to predetermined categories of food.
Because BMI is calculated using only height and weight, the nurse knows that inaccurate findings would most likely occur in a client with diabetes. with osteoarthritis. who is a bodybuilder. who is 182.8 cm (6 ft) tall.
who is a bodybuilder. 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.