Physical Assessment Chapter 8: Nutrition

The nurse is preparing to perform a nutritional assessment for a client. Which of the following questions would be most appropriate to use when initiating the assessment?

"Can you tell me what you've eaten in the last 24 hours?"

An obese teenage boy from a culture that values increased body mass has been referred to the clinic. The nurse is assessing him for malnutrition based on his electronic health record and current health complaints. His mother questions the nurse's rationale, stating, "Anyone can see he's not malnourished. Just look at the size of him!" How should the nurse best respond?

"It's actually very possible for a person to be overweight but have inadequate nutrition."

When obtaining the nutritional health history from a female client, which question would be best to elicit information about the client's knowledge of her own health status?

"What are your height and usual weight?"

A nurse working at a health clinic performs nutritional assessments on a variety of clients in one day. Which of the following clients would be at increased risk for malnutrition? Select all that apply.

1. A single mother of three who makes $20,000 per year 2. A 33-year-old smoker who says that food has lost its taste 3. An elderly woman with Alzheimer's disease 4. A 12-year-old girl with Crohn's disease

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.

1. Check skin turgor 2. Observe skin moisture 3. Inspect tongue condition 4. Palpate radial pulse

You note that your client has developed mental status changes and paresthesias. What would you know to assess as a possible cause for these changes? Select all that apply.

1. Patient's vitamin intake 2. Patient's hydration status

A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply.

1. Sleep apnea 2. Hypertension 3. Diabetes

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?

125

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?

16

A nurse assesses a 114-pound adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client?

19 BMI

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?

24.4

A client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following?

28

Which of the following measurements of waist circumference would lead the nurse to suspect that a female client is at an increased risk for cardiovascular disease and diabetes?

36 inches

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?

46

A nurse is helping a client design a weight-loss diet. To lose 1 pound of fat (3,500 calories) per week, how many calories should be decreased each of the 7 days of the week?

500

A client is interested in losing 15 pounds, and she informs the nurse she is counting her calorie intake each day. The client has a goal of losing 1 pound a week until she reaches her goal. The client asks the nurse how many calories she should decrease daily to lose a pound a week. What is the nurse's best response?

500 calories/day

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

A

Which of the following clients most likely has the greatest need for a folic acid supplement?

A 31-year-old woman trying to become pregnant

Which of the following clients will have an increased metabolic rate and require nutritional interventions?

A person with a serious infection and fever.

The nurse conducting a nutritional assessment should notify the healthcare provider of a possible eating disorder based on which finding?

Absence of menstrual periods

Of the following measurements, which one helps to determine if a client is underweight, normal weight, or obese?

Body mass index.

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

A nurse determines that a client has a body mass index (BMI) of 31.6 kg/m2. The nurse interprets this finding to suggest which of the following?

Class I obesity

You are caring for a client with hypertension. What dietary change would be appropriate to recommend?

Eat more spinach

An older adult client has a body mass index of 15.5 and is consequently considered to be underweight. The client lives alone and states that she has "never been a heavy eater." How can the nurse most accurately assess the client's nutritional habits?

Elicit the client's 24-hour food recall.

In which disease process should a nurse expect to see a client with the presence of pitting edema?

End stage renal disease

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?

Extremely obese

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.

A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. After determining the client's venous filling and emptying each take approximately 10 seconds, the nurse would perform further assessments related to what health problem?

Fluid volume deficit

A nurse is working with a client who has just been given a prescription for warfarin (Coumadin). Which foods should the nurse warn this client to avoid due to its interference with the effectiveness of warfarin?

Green, leafy vegetables

What is the most common indication of nutritional status in infants and children?

Growth

The nurse analyzes the data obtained from a client's nutritional assessment and develops a health promotion diagnosis related to nutrition for a client. Which nursing diagnosis would best for this client?

Health-seeking behaviors related to desire and request to alter amount of food intake

A nurse collects nutritional information on a client. Which statement by the client needs to be validated by careful objective data?

I drink two large bottles of caffeinated beverages every day.

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?

Imbalanced nutrition

When teaching a nutrition class, what would you recommend for adults older than the age of 50?

Increase foods rich in vitamin B12 and calcium

In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate?

Infection

A nurse is working with a client who is Buddhist. Based on what the nurse knows of the common dietary practice of this religion, which nutrient should the nurse make sure that the client is not deficient in?

Iron

A nurse is caring for a client with nasal infection at the healthcare facility. The dietitian has prescribed a diet rich in Vitamin A for the client. The nurse knows that Vitamin A is important for which of the following reasons?

Maintenance of healthy epithelium

After teaching a group of students about malnutrition, the instructor determines that the teaching was successful when the students identify which of the following statements as true?

Malnutrition includes overnutrition and undernutrition.

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?

Measure the arm span to estimate height

The nurse is caring for a client recovering from surgery with an open wound. The nurse should encourage this client to increase the intake of which foods?

Meat and dairy products.

Foods rich in iron include all of the following except:

Milk

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?

Obese

What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?

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

A client has just had abdominal surgery and the nurse is consulting with the client about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

Protein

Which of the following problems results from a deficiency in vitamin D?

Rickets

A nurse is providing nutritional instruction at a health fair. She instructs passersby on the characteristics of a nutrient that is the body's first source of energy, sparing use of other nutrients for this purpose, that raises the blood glucose level, is found in fruit juices, and that can be converted quickly into energy. To which of the following nutrients is the nurse referring?

Simple carbohydrates

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?

Sunshine

The nurse is providing care for a client with a history of chronic heart failure. The client is in bed with the head of her bed at 45 degrees, and the nurse is assessing the client's neck veins. What assessment finding would be most consistent with a nursing diagnosis of fluid volume excess related to chronic heart failure?

The client's jugular veins are clearly visible and firm to palpation.

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?

Vitamin B

Which measurement should the nurse add to the body mass index to increase the predictive ability for the client?

Waist circumference

What is the most common measurement used to determine abdominal visceral fat?

Waist circumference.

Bulimia differs from anorexia in that bulimics

crave food

Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 448 mg/dL. Which of the following would be the priority?

risk for dehydration related to inadequate oral intake and frequent urination