Chapter 13 Nutrition
Write down the hunches based on the cue cluster After the nurse has completed identifying the abnormal data and strengths, and has clustered the related data, the nurse should then write down hunches based on the cue cluster. Only after writing down the hunches based on the cue cluster can the nurse hypothesize and generate possible nursing diagnoses, check the defining characteristic of the cluster to choose an accurate diagnosis, and verify the diagnosis with the client and other health care professionals.
A nurse analyzes the data obtained from the assessment of a client. The nurse has identified and clustered the abnormal data and strengths of the client. What should the nurse do next when analyzing the data?
24.4
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?
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 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
38 grams Adequate total fiber intake is 25 grams per day for adult women and 38 grams per day for men
A nurse is advising a 40-year-old male client on his dietary fiber intake. Which of the following should the nurse indicate would be an adequate total fiber intake per day?
Helping transport oxygen and lipids through the circulatory system Acting as enzymes for chemical reactions such as digestion Making hormones such as insulin
A nurse is instructing a client on the importance of protein in the diet. Which of the following should the nurse mention as functions of proteins in the body? Select all that apply.
"Hair consists mostly of protein."
A teenage client with cancer asks the nurse what hair is made of. What would be the nurse's best answer?
Nails are strong Nails are strong; is the documentation that represents a normal finding. Clothing that is too largemight indicate weight loss. Thin, oily hair is not generally a normal finding, nor are white patches on the oral mucosa.
After assessing a new client, the nurse documents findings in the medical record. What is the best example of documenting normal findings?
Validate the client's identified problems. The nurse should develop a plan of care while adhering to the nursing process. After assessment, the client's problems should be validated. Mutual goal setting is recommended versus nurse-driven goal setting. Nursing actions should not be implemented before the plan of care is developed. The plan of care can not be completed until the client's problems are validated and mutual goals are set.
After collecting subjective and objective data for the admission database, what is the nurse's next action?
30-39 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.
An individual is considered obese when his or her BMI is:
20%
At what percent of weight over ideal weight is a person considered obese?
Obtain a 24 hour dietary recall of all foods and fluids consumed
How can a nurse best assess a client's dietary habits?
"Whole milk is recommended until age 2." 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.
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?
Extremely obese A person with a BMI below 18.5 is underweight, a BMI of 25 to 29.9 indicates an overweight individual, a BMI of 30 or greater indicates obesity, and a BMI of 40 or greater indicates extreme obesity.
Upon assessment, the nurse determines the patient has a body mass index (BMI) of 45. This finding indicates the patient is which of the following?
Vitamin B The suggested implication for a red, beefy tongue is vitamin B deficiency. The finding of a red, beefy tongue in a client does not indicate thiamine deficiency, or iodine or niacin deficiency. Altered mental status is due to thiamine deficiency. A swollen neck is caused by iodine deficiency. Cracks in the corners of the mouth are because of niacin deficiency.
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?
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 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?
Reducing her weight by 5% can lower her risk 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 patient 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
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 patient?
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.
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?
health maintenance Health maintenance includes any preventative diagnostics or health-promoting activities the client completed in the past. This is a subsection of the past history in the health assessment. The physical examination and review of systems capture the objective data that arises from the health assessment conducted by the nurse. Personal and social history capture client lifestyle factors such as family, employment, and habits.
A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?
Fluid volume less than body requirements related to an inability to tolerate fluids
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?
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 105-pound adult client who is 5 feet 8 inches tall. What is the estimated body mass index (BMI) for this client?
19 The BMI is calculated by dividing weight in pounds and height in inches multiplied by 703. The body mass index calculated by the nurse should be 19 for a client who is 5 feet 5 inches tall. 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 his or her body mass index, which can be calculated regardless of the client's gender.
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?
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
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?
Accessibility The older adult client who is unable to drive will have limited access to a range of foods that will promote nutritional health. The correct option is accessibility. Food preparation seeks to determine who does the cooking for the client and the way in which the foods are prepared. Finances refers to having access to sufficient funds to purchase foods that support nutritional health. Food preferences are personal for each client and refer to likes or dislikes. In addition, the client may report foods they find harmful or beneficial and cultural or religious preferences in this assessment area.
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?
125 Ideal body weight for a female is 100 lb for 5 ft + 5 lb for each inch over 5 ft plus or minus 10% for small or large frame. For this female client with a medium frame, the formula would be as follows: 100 lb + 25 lb = 125 lb.
A nurse is calculating the ideal body weight for a female client who 5 feet 5 inches and has a medium body frame. Which of the following is this client's ideal body weight?
To assess if the patient has the ability to obtain or prepare food Functional limitations influence the ability to obtain or prepare food. The nutrition-metabolic pattern involves more than just the nutrients ingested each day. It encompasses aspects such as culture, religion, and geography; food and fluid preferences and dislikes; patterns of eating, digestion, and allergies; shopping resources and skills; and kitchen facilities and food preparation.
A nurse is conducting a comprehensive nutritional assessment on a patient with suspected malnutrition. Why would it be important to assess this patient's ability to cook?
145 lb 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 is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this patient's ideal weight?
28.5 cm The standard MAC is based on the client's sex and age. This is a human body composition measurement, which helps to evaluate the client's nutritional status. The standard reference of MAC for an adult female client is 28.5 cm. Ninety percent of the standard reference of MAC in an adult female is 25.7 cm and represents one who is moderately malnourished. The standard reference of MAC is 29.3 cm in adult males. Ninety percent of the standard reference of MAC in adult males is 26.3 cm and represents one who is moderately malnourished.
A nurse is measuring an adult female client's mid-arm circumference (MAC) as part of her overall assessment of the client's nutritional status. Which of the following is the standard reference for the MAC for an adult female?
Cholesterol Cholesterol is a fatlike substance that the liver produces. A high level of cholesterol can lead to heart attacks and strokes. However, cholesterol is important to normal bodily functions. It is necessary as a 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. Ingested fats are saturated, originating from animal sources or tropical oils and solid at room temperature, or unsaturated, originating from plant sources and soft or liquid at room temperature. Fats serve many functions in the body, but not the ones listed here. The primary functions of protein are growth, repair, and maintenance of body structures and tissue.
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?
Skinfold thickness Skinfold calipers are used to measure triceps skinfold thickness to evaluate the degree of subcutaneous fat stores. Body mass index is calculated by first measuring height and weight by means of a balance beam scale with height attachment and then entering these values into a formula. A tape measure is used to measure waist and mid-arm circumferences.
A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking?
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.
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
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 nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present?
Sleep apnea Hypertension Diabetes
A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply.
40 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.
A waist circumference of greater that which of the following is indicative of excess abdominal fat in men?
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
Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease?
Prolong confinement to bed Malnutrition interferes with wound healing, increases susceptibility to infection, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of patients to bed. Therefore options A, B and C are incorrect.
Malnutrition can be too much or too little nutrition. What can malnutrition do in the human body?
a client with body mass index of 27 and blood pressure of 145/80 mm Hg The client with a body mass index (BMI) of 27 is overweight and has hypertension. The nurse should offer strategies for weight loss to prevent the progression of cardiovascular disease. A client with a BMI of 18.5 borders on normal and underweight. Despite having a family history of heart disease, the client should be discouraged from further weight loss. Other risk factors for heart disease should be identified and treated as necessary. The client with a BMI of 23 is in the normal range; therefore, pursuing weight loss is not indicated. Further monitoring of the LDL cholesterol is warranted, however. The client with a BMI of 25 would be considered on the borderline of the overweight category; however, the HDL cholesterol is normal. Cardiovascular risk associated with the BMI is not higher in the absence of other risk factors.
It would be a priority for the nurse to provide counseling about nutrition and exercise for weight loss for which client?
Ambulation assistance The RN may delegate individual components of care but does not delegate the nursing process itself. The main functions of assessment, planning, evaluation, and nursing judgment cannot be delegated. For example, if the nurse delegates taking vital signs to a nursing assistant, he or she is responsible for making sure that the data is accurately collected and for following up if findings are abnormal. The nursing assistant may collect vital signs, but the RN is responsible for evalutation. Assessment is always the RN's responsibility, which includes wound assessment and assessing pain level.
The RN may delegate which care component to a nursing assistant?
absence of menstural cycle 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.
The nurse conducting a nutritional assessment should notify the healthcare provider of a possible eating disorder based on which finding?
Impaired comfort related to headache and sore throat pain The priority diagnosis is related to the chief complaint of headache and sore throat.
The nurse gathers the follow data: complaint of headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature 100.6°F orally. It was noted that the patient had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be
"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?
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 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?
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.
To calculate the ideal body weight for a woman, the nurse allows
Overhydration Edema may be secondary to a protein deficiency or overhydration in a patient with a weak heart.
What can cause edema in a patient with a weak heart
Waist circumfrence
What is the most common measurement used to determine abdominal visceral fat?
Place the tape measure behind the client and measure at the umbilicus 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.
What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?
5 When calculating ideal body weight for women, add 5 pounds for each additional inch over 5 feet.
When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet?
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.
When teaching a nutrition class, what would you recommend for adults older than the age of 50?
Patient's hydration status Note changes in mental status, irritability, inability to concentrate, or paresthesias. Dehydration and lack of vitamins may cause these symptoms.
You note that your patient has developed mental status changes and paresthesias. What would you know to assess as a possible cause for these changes?