Chapter 13: Assessing Nutritional Status

A nurse is providing nutritional teaching for a client with a body mass index (BMI) of 30. What teaching should the nurse provide? -"Decrease your daily caloric intake and increase your physical activity." -"Continue with your current food intake and exercise regimen." -"Increase your daily physical activity and calories by 500 a day." -"Decrease your daily physical activity and increase your caloric intake."

"Decrease your daily caloric intake and increase your physical activity."

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 should be exercising for longer periods of time." "You are retaining fluid." "Your metabolism is slowing down." "You could be making healthier food choices."

"Your metabolism is slowing down"

A client is prescribed serial weight measurements every day. What action(s) will the nurse take when conducting these serial weights? Select all that apply. -Have the client wear similar clothing every day. -Weigh the client at the same time in the morning. -Use the same scale to weigh the client. -Weigh the client after eating the morning or midday meal. -Encourage the client to look at the balance beam.

-Have the client wear similar clothing every day. -Weigh the client at the same time in the morning. -Use the same scale to weigh the client.

A 17-year-old client who consumes a vegetarian diet is diagnosed with an iron deficiency. What dietary instruction(s) should the nurse provide to this client? Select all that apply. -Increase the intake of yogurt, milk, and cheeses. -Increase the intake of rich greens, such as spinach and Swiss chard. -Increase the intake of enriched and whole-grain bread. -Increase the intake of iron-fortified cereals. -Increase water intake.

-Increase the intake of rich greens, such as spinach and Swiss chard. -Increase the intake of enriched and whole-grain bread. -Increase the intake of iron-fortified cereals.

A client has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply. -medications -blood pressure -temperature -cholesterol -activity level

-activity level -cholesterol -blood pressure

A nurse is helping a sedentary 20-year-old female determine her dietary needs. Which of the following would be her estimated calorie needs per day? 1,800-2,000 2,200-2,400 2,000-2,200 1,600-1,800

1,800-2,000

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? -145 lb -130 lb -140 lb -135 lb

145 lb

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 -20 BMI -19 BMI

19 BMI

At what percent of weight over ideal weight is a person considered obese? -60% -20% -100% -40%

20%

A nurse assesses a 175-pound adult client who is 5 feet 11 inches tall. What is the estimated body mass index (BMI) for this client? -18.9 -24.4 -29.9 -34.4

24.4

An individual is considered obese when his or her BMI is: -Greater than 40 -30-39 -Less than 24 -25-29

30--39

A waist circumference of greater that which of the following is indicative of excess abdominal fat in men? 30 40 35 25

40

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? -29 -52 -46 -34

46

When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet? -7 -3 -5 -1

5

A client describes probable night blindness. Intake of what vitamin should be evaluated? C A D B

A

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 27-year-old woman with pneumonia A 39-year-old who has been in remission from cancer for 4 years A 42-year-old client with irritable bowel syndrome A 33-year-old athlete on steroids

A 33-year-old athlete on steroids

A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status? -Accessibility -Food preferences -Finances -Food preparation

Accessibility

The nurse in a long-term care facility is caring for an older adult client who had a 7% weight loss over a two-year period. Which is an expected intervention based on the information? Assess the client's dentures for proper fit. Ask the client to eat in their room to avoid distractions at mealtime. Place the client on fall risk precautions. Teach the client to choose food low in protein.

Assess the client's dentures for proper fit

Waist circumference guidelines may not be accurate for adult clients who are shorter than 152.4 cm (5 ft) in height. This restriction is also a concern for which other anthropometric measurement? -Triceps skinfold measurements. -Mid-arm circumference. -Ideal weight. -Body mass index (BMI).

Body mass index (BMI).

A nurse is working with a client with a chronic disease that has contributed to the client developing cachexia, a type of malnutrition. As a result, the client demonstrates abnormal metabolic rate, anorexia, muscle wasting, severe weight loss, and general decline in condition. Which chronic disease, strongly associated with cachexia, does the client most likely have? -Diabetes -Cardiovascular disease -Cancer -Osteoporosis

Cancer

The nurse should perform which priority assessment on a client with a history of a high hydrogenated fat intake? -Skin -Cardiac -Musculoskeletal -Respiratory

Cardiac

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? Saturated fat Unsaturated fat Cholesterol Protein

Cholesterol

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. -Clients with a BMI of 23. -Males with 88.9 cm (35 in) or greater waist circumference. -Clients with a BMI of 20.

Females with 88.9 cm (35 in) or greater waist circumference.

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? -Fluid volume, excessive -Imbalanced nutrition -Activity intolerance -Knowledge deficit

Imbalanced nutrition

When teaching a nutrition class, what would you recommend for adults older than the age of 50? Increase foods rich in vitamin B6 and vitamin D Increase foods rich in vitamin E and folic acid Increase foods rich in vitamin B6 and saturated fats Increase foods rich in vitamin B12 and calcium

Increase foods rich in vitamin B12 and calcium

A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. What conclusion is suggested if the client has no reaction? -It may be immunosuppression resulting from undernourishment. -It is indicative of unhealthy dietary habits. -It indicates high cholesterol and triglyceride levels. -It shows a sacrifice of skeletal muscle proteins and blood proteins.

It may be immunosuppression resulting from undernourishment.

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 -Use a standard chart for height by age and gender -Provide support or hold the client to record the height -Measure the arm span to estimate height

Measure the arm span to estimate height

After assessing a new client, the nurse documents findings in the medical record. What is the best example of documenting normal findings? -Hair is thin and appears oily -Clothing appears too large -Oral mucosa is pink with white patches -Nails are strong

Nails are strong

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 -Ask the client to be seated and relaxed when taking the measurement -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

Place the tape measure behind the client and measure at the umbilicus

A nurse obtains a height measurement on an elderly client and notes that the height has decreased from 5 years ago. What is an appropriate action by the nurse? -Obtain a height with the client lying down on the exam table -Record this measurement in the client chart and alert the health care provider -Measure the arm span and record the taller measurement -Compare the new height to the client weight to assess for changes in body mass index (BMI)

Record this measurement in the client chart and alert the health care provider

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? -Reduce daily calorie intake by 100 calories each day. -Reducing her weight by 5% can lower her risk -Structure eating so that no more than 500 calories are consumed each day. -Plan to reduce weight by 20% in 6 months.

Reducing her weight by 5% can lower her risk

A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking? -Waist circumference -Mid-arm circumference -Body mass index -Skinfold thickness

Skinfold thickness

When would a nurse obtain a mid-arm circumference measurement? -To assist in determining body mass index. -To screen for nutritional excess or deficits. -To confirm an abnormal albumin level. -To provide percentage of body fat and muscle tissue.

To provide percentage of body fat and muscle tissue.

When beginning a height measurement on a 14-year-old, the nurse should instruct the client to stand on the scale with heels together. False True

True

When performing a nutritional assessment on a client, a nurse observes that the client has a red, beefy tongue. The nurse recognizes this finding as a deficiency of which essential nutrient? -Niacin -Iodine -Thiamine -Vitamin B

Vitamin B

During a physical assessment, a client reports he has had an inflamed sore on his arm for 2 weeks with no signs of healing. The nurse notes the client also has bleeding gums. What do these findings suggest regarding the client's nutritional status? -Vitamin B12 deficiency -Vitamin C deficiency -Vitamin D deficiency -Vitamin A deficiency

Vitamin C deficiency

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 -Mid-arm circumference -Triceps skinfold measurement

Waist Circumference

The charge nurse is prioritizing the review of intake and output records. Which client's records should be reviewed first? -a client who has burns to 60% of their body -a client who was admitted with acute pain caused by gout -a client who underwent hip arthroscopy two days ago -a client who was admitted with malignant hypertension

a client who has burns to 60% of their body

It would be a priority for the nurse to provide counseling about nutrition and exercise for weight loss for which client? -a client with body mass index of 18.5 and family history of heart disease -a client with a body mass index of 23 and high LDL cholesterol -a client with body mass index of 27 and blood pressure of 145/80 mm Hg -a client with a body mass index of 25 and normal HDL cholesterol

a client with body mass index of 27 and blood pressure of 145/80 mm Hg

While conducting a physical examination, the nurse notices the client's mucous membranes are pale in color. Which nutritional deficiency is most likely for this client? protein vitamin A vitamin C anemia

anemia

Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is which of the following? -Underweight -Normal weight -Extremely obese -Obese

extremely obese

A nursing instructor is teaching nursing students how to perform a nutritional assessment, collecting both objective and subjective data. The nursing instructor determines understanding of the differences between objective and subjective findings when the students identify which of the following as subjective data? -laboratory values -height and weight -health history interview -anthropometric measurements

health history interview

A client is admitted with difficulty breathing, abdominal distention, a 5 pound weight gain in the past week and yellowing of the skin. Which of the following underlying problems might be contributing to the client's weight gain? -liver dysfunction -overhydration -obesity -respiratory condition

liver dysfunction

The nurse measures the height and body weight of a female client with high muscle mass. The client weighs 175 pounds (79.4 kg) and is 68 inches (173 cm) tall. In which of these categories does the client's body mass index (BMI) fit best? -overweight -normal -underweight -obese

normal

The nurse is preparing to measure the triceps skinfold of an adult client. The nurse should -measure the triceps skinfold in the dominant arm. -repeat the procedure three times and average the measurements. -ask the client to assume a sitting position. -pull the skin toward the muscle mass of the arm.

repeat the procedure three times and average the measurements.

What is the best measure of protein stores in the body when assessing nutritional status? -Albumin -Total protein -Prealbumin -Transferrin

total protein

A nurse is teaching a class on diet and nutrition to a group of mothers who are breast-feeding their infants. What would the nurse tell the group is the emphasis of nutritional guidelines? -Decreased intake of grains -Weight loss -Increased intake of meats -Variety

variety

What is the most common measurement used to determine abdominal visceral fat? -Triceps skinfold thickness. -Subcutaneous fat determination. -Waist circumference. -Body mass index.

waist circumference