Physical Assessment in Health Care Quiz 2

Which questions are appropriate for the nurse to ask a client that is obese in regards to nutritional status? Select all that apply.

"Are any members of your family obese?" "How do you decide your diet?" "What is your height and usual weight?"

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?"

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 protein."

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?

"Whole milk is recommended until age 2"

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

An adult 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

An individual is considered obese when his or her BMI is:

30-39

A nurse is performing nutritional assessments at a health fair. Which of the following clients is at highest risk for health-related problems?

45-year-old female with fat located primarily around the waist

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

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

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

Absence of menstrual periods

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?

Cancer

Which vessel is the nurse assessing if the major artery of the neck is being examined?

Carotid

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

Diabetes Hypertension Sleep apnea

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

Eat more spinach

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment

A client suffering from decreased muscle strength has been diagnosed with a low vitamin D level. The nurse should recommend that the client increase which vitamin source?

Exposure to sunshine

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect?

Hypothyroidism

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

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

You are the nurse caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?

Iodine

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 school nurse is assisting with taking baseline measurements of students at a middle school who are participating in a summer fitness program. Which pieces of equipment should the nurse gather specifically for taking anthropometric measurements? Select all that apply.

Marking pencil Skinfold calipers Balance beam scale with height attachment Metric measuring tape

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?

Meningitis

A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

Migraine

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

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

On each side between the top of the ear and the eye

Higher sodium intake is associated with all of the following except:

Osteomalacia

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

Parkinson's disease

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 nurse is using calipers to assess a client. Which of the following measurements is the nurse taking?

Skinfold thickness

A nurse is palpating the position of the trachea. At which anatomic site would the nurse first position a finger for palpation?

Sternal notch

A nurse reviews the findings of an admission assessment. The nurse will determine the client meets the criteria of obesity based on which of the following findings?

The client weighs 20% more than ideal body weight (IBW)

A nurse is conducting a comprehensive nutritional assessment on a client with suspected malnutrition. Why would it be important to assess this client's ability to cook?

To assess if the client has the ability to obtain or prepare food

A 34-year-old woman who is conscientious about fostering and maintaining her health has brought up the question of trans fats after hearing a great deal about the subject in recent media reports. Which of the following statements from the nurse about trans fats is most accurate?

Trans fats are associated with an increased risk for cardiovascular disease.

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?

Variety

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

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 with a body mass index of 14 refuses to eat breakfast and cuts up the food for lunch and dinner but does not eat anything. What should the nurse suspect this client is demonstrating?

anorexia nervosa

Bulimia differs from anorexia in that bulimics

crave food

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

After performing a nutritional assessment on a client, the nurse determines the client is at high risk for undernutrition based on which of the following findings? Select all that apply

long sedentary work hours problems with dentition chronic diseases depression

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

migraine headache.

The nurse analyzes the data to develop a care plan for a client based on an actual client concern for a 24-year-old client's nutritional status. For which client concern should the nurse create the care plan?

poor body image associated with significant recent weight loss

A group of students is reviewing information about general indicators for nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator for good nutritional status?

thinning, dry hair