Chapter 36: Nutrition
A client tells the nurse, "As long as I only eat 2,400 calories per day, it does not matter which foods I eat." Which response by the nurse is best?
"Can you share an example of what you ate yesterday?" Explanation: Healthy adult client on average require 1,800 to 2,400 cal/day. Unless the caloric intake includes an appropriate mix of proteins, carbohydrates, and fats, the person may be marginally nourished or malnourished. In other words, consuming 2,400 calories of chocolate, exclusive of any other food, is not adequate to sustain a healthy state. By asking the client for an example of the foods eaten, the nurse can help the client plan effectively. It is important to teach clients about healthy nutrition, so this response is most appropriate. The other responses from the nurse are not correct.
A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching?
"My husband and I are ordering a product that has megadoses of vitamins." Explanation: Consuming megadoses (amounts exceeding those considered adequate for health) of vitamins and minerals can be dangerous. This statement requires further nursing teaching. The other statements do not require further teaching.
A nursing student is teaching healthy nutrition to a client who is vegetarian. Which statement by the nursing student requires the nursing instructor to intervene?
"Obesity is closely linked with vegetarianism." Explanation: Vegetarians have a lower incidence of colorectal cancer and fewer problems with obesity and diseases associated with a high-fat diet. Protein complementation involves eating a variety of incomplete plant proteins over the course of the day to provide adequate amounts and proportions of all the essential amino acids present in animal protein sources. Vegans rely solely on plant sources for protein; semi-vegetarians exclude only red meat from their diet. Obesity is not linked with vegetarianism.
A client informs the nurse that they have been following a strict low-calorie diet and skipping meals to lose weight faster. The client reports feeling upset about not losing any weight and wants to know what to do. What is the best response by the nurse?
"The body will go into starvation mode by slowing metabolic rate and it will be hard to lose weight." Explanation: Fasting or following a very-low-calorie diet may defeat a weight-loss plan because the body interprets this eating pattern as starvation and compensates by slowing down the resting metabolic rate, making it even more difficult to lose weight.
The nurse is educating a client taking furosemide for heart failure about eating foods that are rich in potassium. Which statement made by the client indicates that education was effective?
"When I take my medication, I will eat a banana or take it with a glass of orange juice." Explanation: The client demonstrates that the teaching was effective by identifying bananas and orange juice as foods rich in potassium. The desired effect of the medication is to excrete sodium to avoid the accumulation of fluid in the lungs. To increase the amount of salt in the diet would be counterproductive. Dairy products such as milk and cheese are not potassium-rich foods. Eating small frequent meals versus three meals per day is irrelevant in increasing potassium level.
What is the body mass index (BMI) of a client who is 1.68 meters tall and weighs 70 kg?
24.8 Explanation: A BMI of 24.8 is correct. The BMI is the ratio of height to weight that more accurately reflects total body fat stores in the general population. To calculate the BMI: divide the weight in kilograms (kg) by the height in meters (m) then divide the answer by the height again to get the BMI.
The nurse is caring for four clients. The nurse recognizes that which client's lifestyle choice contributes most highly to risk for development of cardiometabolic syndrome?
28-year old who eats fast food daily Explanation: The client with the modifiable risk factor of consuming daily fast food is at highest risk for developing cardiometabolic syndrome. The other clients are not at as high of a risk.
At what period of life do nutrient needs stabilize?
Adulthood Explanation: Nutrient needs change across the life span in relation to growth, development, activity, and age. Periods of intense growth and development (such as during infancy, adolescence, pregnancy and lactation) increase nutrient needs. Nutrient needs stabilize during adulthood.
The nurse is attempting to insert an NG tube and, as the tube is passing through the pharynx, the client begins to retch and gag. What nursing interventions are appropriate in this situation? Select all that apply.
Ask the client if he needs to pause before continuing insertion. Continue to advance tube when the client relates that he is ready. Have the emesis basin nearby in case client begins to vomit. Explanation: The nurse would ask the client if she should pause before continuing insertion of the NG tube. The client retching and gagging is often part of the normal process of placing an NG tube. The nurse would continue to advance the tube when the client states he is ready. The emesis basin should be nearby in case the client begins to vomit. The nurse would not inspect the other nostril; if the client is retching and gagging, the issue is not the nostril. The nurse would not give small air boluses or insert a nasointestinal tube.
The nurse has obtained a client's capillary blood glucose sample and the results are significantly lower than reference range. What is the nurse's priority action?
Assess the client for signs and symptoms of hypoglycemia. Explanation: Low blood sugars should prompt the nurse to assess for signs and symptoms of hypoglycemia. There may or may not be a need to contact the primary care provider depending on whether a protocol is in place and the client's clinical presentation. There is not normally a need to obtain a sample from the opposite hand.
A nurse is caring for a client who has a nursing diagnosis of Risk for Aspiration. When preparing to assist this client with eating, how can the nurse best reduce this risk?
Assess the client's level of consciousness. Explanation: Decreased level of consciousness greatly increases a client's risk of aspirating; it is imperative that the nurse assess this prior to the client eating. It is appropriate for the nurse to assess the client's mouth and abdomen and assess for nausea, but none of these actions directly address the client's risk of aspiration.
The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?
Assess when client generally eats meals. Explanation: There are many reasons a client may refuse food that is served. The nurse should assess for food preferences, when the client generally eats, whether the client has digestive concerns, and cultural beliefs about foods. Leaving the client alone to eat, or simply delegating feeding, does not encourage intake. The client does not need an appetite stimulant until a full assessment has been conducted and other interventions have been implemented.
A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?
Blood from the fingertips shows changes in glucose more quickly than other testing sites. Explanation: With glucose monitoring, blood from the fingertips shows changes in blood glucose more quickly than other testing sites. With signs and symptoms of hypoglycemia, a fingertip site should be used. Calibrate the glucose monitors at least every month. Glucose levels increase with illness and stress to the body.
An athlete wants to increase her intake of complex carbohydrates and asks the nurse about potential sources. Which food is considered a complex carbohydrate?
Bread Explanation: Bread, cereal, potatoes, rice, pasta, crackers, flour products, and legumes contain complex carbohydrates.
The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take?
Check the medical record for the client's prescribed diet. Explanation: The nurse ensures the client has received the correct meal tray. Often a client on a dysphagia diet will have a special diet that includes softer or pureed foods and thickened liquids that aren't available on the regular diet tray. The other actions are not incorrect, but the client may not be on a chopped food diet. Sometimes the client with dysphagia just requires sips between bites, and there is no reason to use foods from the unit's kitchen area. The best action the nurse can take is to ensure the client get the correct meal tray.
A nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client?
Drink juice for majority of fluid intake. Explanation: Water should comprise the majority of fluid intake. The remainder should come from food sources such as fruit or 100% fruit juices.
A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first?
Ensure the head of the bed is elevated. Explanation: The head of the bed should be elevated before giving medications or performing a tube feeding. Following this, the placement of the tube should be checked, aspirate the gastric contents with a syringe, and then flush the tube with the ordered amount of water.
A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?
Every 4 to 6 hours Explanation: Checking for residual before each feeding or every 4 to 6 hours during a continuous feeding according to institutional policy is implemented to identify delayed gastric emptying. Residuals are not measured immediately after a flush.
A nurse is assessing a client's nutritional status. Which findings should lead the nurse to suspect poor nutritional status?
Flaky facial skin, facial edema, and pale skin color Explanation: Healthy facial skin is uniform in color and not flaky, swollen, or pale. The other findings indicate good nutritional status.
A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs?
Gastrostomy tube Explanation: When enteral feeding is required for a long-term period, an enterostomal tube may be placed through an opening created into the stomach (gastrostomy) or into the jejunum (jejunostomy). NG, NI, and Salem Sump tubes will not meet a client's long-term nutritional needs.
The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550 mL. The previous residual was 200 mL. What action should the nurse take?
Hold the enteral nutrition and notify the primary care provider. Explanation: When the residual is greater than 500 mL, the enteral feeding should be held and the primary care provider (PCP) needs to be called for further instructions. If there had been two consecutive residuals >250 mL, the PCP would consider ordering a promotility agent. The PCP will consider decreasing the rate of the tube feeding and may or may not want the residual returned since it is so large. The nurse would not discard or replace the residual and merely chart the amount of the residual and continue the tube feeding at the ordered current rate. The excessive large residuals will increase the client's risk for aspiration.
A nurse is delivering meal trays to clients on the unit. One client has a fractured dominant arm which is in a sling. What is the first nursing action when bringing the tray into the client's room?
Identify the name of the client. Explanation: When serving meal trays, the nurse first identifies the name of the client to ensure the client receives the correct meal tray. The nurse will then assist this client, who has limited mobility of the arm, in preparing the food by removing lids from the food items, opening cartons of fluids, and cutting food into bite-sized pieces.
Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube?
If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. Explanation: The nurse would measure the volume and pH of the aspirated fluid, then flush the tube with water. The nurse would not place the client in Trendelenburg position as this could lead to reflux of the feeding from the stomach and possibly cause aspiration of the solution into the lungs. The nurse would not use a small syringe or continue to instill air until fluid is aspirated.
A nurse is caring for a client with a gastrostomy tube in place. Which is an accurate guideline for care of the insertion site?
If the gastric tube insertion site has healed and the sutures are removed, use soap and water to clean the site. Explanation: If the gastric tube insertion site has healed and the sutures are removed, wet a washcloth and apply a small amount of soap onto it. Gently cleanse around the insertion site, removing any crust or drainage. If the gastrostomy tube is new and still has sutures holding it in place, dip a cotton-tipped applicator into sterile saline solution and gently clean around the insertion site, removing any crust or drainage. Avoid adjusting or lifting the external disk for the first few days after placement, except to clean the area.
What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding?
If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog. Explanation: Warm water and gentle pressure should be used to unclog a tube. If a large amount of residue is accidentally aspirated, the health care provider should be notified. If the client is nauseated, the head of the bed should remain elevated and an antiemetic administered as prescribed. The tube should be in the stomach, not the esophagus.
A client who is recovering from a stroke has begun tube feedings. Which principle should the nurse follow when administering the tube feeding?
Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time. Explanation: Intermittent feedings are delivered at regular intervals, using gravity for instillation or a feeding pump to administer the formula over a set period of time. The steps for administering feedings are similar regardless of the tube used. Intermittent feedings are the preferred method of introducing the formula over a set period of time via gravity or pump. Feeding intolerance is less likely to occur with smaller volumes. Feeds are not warmed prior to instillation.
The nurse is caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?
Iodine Explanation: A chronic deficiency of iodine can lead to endemic goiter. The major initial symptom is an enlarged thyroid gland.
During a visit to the pediatrician's office, a parent inquires about adding solid foods to the diet of a 6-month-old infant. What does the nurse inform the parent?
New foods should be introduced one at a time for a period of 2 to 3 days. Explanation: Solid foods are generally introduced between 4 and 6 months of age. New foods should be introduced one at a time for a period of 2 to 3 days so that any allergic reaction can be identified. Iron-fortified foods are recommended.
A nurse is removing an NG tube and notes epistaxis. What nursing interventions would the nurse perform in this situation? Select all that apply.
Occlude both nares until bleeding has subsided. Ensure that client is in upright position. Document epistaxis in client's medical record. Explanation: The nurse would occlude both nares until bleeding subsided. This would help to stop the nosebleed. The nurse would ensure that the client is in the upright position. This will help the client from swallowing blood, which could lead to nausea and emesis. The nurse would document the episode in the client's medical record. The nurse would not contact the primary care provider if the nurse is removing the tube. There would be no need to reinsert the tube if a nosebleed occurred when removing the tube. The nurse would not encourage the client to blow the nose, as this will not help the nosebleed to stop. There would not be blood in the suction container if the nurse is removing the NG tube and the nosebleed occurred.
The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:
RDA level Explanation: The RDA level is the average dietary intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group.
The nurse is caring for a 70-year-old client with a body mass index (BMI) of 34.8. Which risk factor should the nurse discuss with this client?
Risk of heart disease Explanation: A client with a BMI of 34.8 is obese and is at highest risk for heart disease, diabetes, and some types of cancer. Being underweight can increase the risk for infections, osteoporosis, and other health conditions.
Which laboratory test is the best indicator of a client in need of TPN?
Serum albumin Explanation: Assessment of serum albumin level is the best indicator of a client in need of total parenteral nutrition (TPN). Clients whose levels are 2.5 g/dL (25 g/L) or less are at severe risk for malnutrition. Creatinine is used to assess kidney function. Hemoglobin and hematocrit assess the red blood cells of a client.
A nurse is caring for a client who has a malabsorption disease. The nurse should understand that which structure in the gastrointestinal system absorbs the majority of digested food and minerals?
Small intestine Explanation: Most absorption of digested food and minerals occurs in the small intestines. The stomach is responsible for storing food, secreting digestive enzymes, and digestion. The large intestine forms feces and absorbs water to regulate the consistency of stool. The digestive function of the liver is the production of bile.
The nurse is reviewing a client's laboratory report. The report indicates the client's albumin level is 2.89 g/L (4.19 mmol/L). Which inference can the nurse make about the laboratory result?
The client has malnutrition Explanation: Serum albumin values reflect protein intake or absorption. Values of less than 3.5 g/dL (5 mmol/L) may indicate nutritional deficits and malnutrition or malabsorption.
A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason?
To rest the gastrointestinal tract and promote healing Explanation: Withholding food may be indicated in the following situations: to rest the gastrointestinal tract to promote healing, clear the gastrointestinal tract of contents before surgery or diagnostic procedures, prevent aspiration during surgery or in high-risk clients, give normal intestinal motility time to return, treat severe vomiting or diarrhea, and to treat medical problems, such as bowel obstruction or acute inflammation of the gastrointestinal tract. Withholding food does not cause gas to accumulate or increase the amount of mucus in the bowel.
A physician orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition?
Total parenteral nutrition (TPN) Explanation: TPN is nutritional therapy that bypasses the gastrointestinal tract and is administered through a central vein. PPN is nutritional therapy used for clients who have an inadequate oral intake and require supplementation of nutrients through a peripheral vein. A PEG is a surgically placed gastrostomy tube. A PEJ is a surgically placed jejunostomy tube.
The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite?
Try to ensure that the client's food is attractive and sufficiently warm. Explanation: Food in the health care setting can often be unattractive and cool. Ensuring that it is appealing to the eyes and presented at the correct temperature can stimulate the client's appetite. Meals should be small and more frequent, not less frequent and larger. Supplements may be nutritionally necessary, but these do not act to increase the client's appetite.
A family meeting has been called to discuss care planning for a client who has late-stage Alzheimer disease and who has largely stopped taking food by mouth. What principle should best guide the decision around the use of tube feeding?
Tube feeding has not been shown to increase survival rates significantly among this population. Explanation: Research is recommending that tube feedings should not be used for clients with dementia since they do not increase survival or prevent malnutrition or aspiration. Clients do not need to be able to manipulate their system independently.
The client reports to the nurse that she feels as if her eyes are persistently dry. This symptom is consistent with a deficiency in which dietary element?
Vitamin A Explanation: Dryness of the eyes (xerophthalmia) is associated with a deficiency of vitamin A.
Which of the following is a fat-soluble vitamin?
Vitamin E -Fat-soluble vitamins: A, D, E, and K
A client who has bleeding tendencies has a deficiency in which vitamin?
Vitamin K Explanation: Vitamin K deficiencies are manifested in two ways: an increased tendency to hemorrhage and hemorrhagic disease of the newborn, which is common in premature or anoxic newborns.
The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR?
a client who has a fever Explanation: A client who has a fever would have an increased BMR. The energy needs of the body are increased due to the client's fever. The BMR is decreased in an older adult client, a client who is fasting, and a client who is asleep.
The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk?
adolescent who is in the second trimester of pregnancy Explanation: Children, adolescents, pregnant women, and breast-feeding mothers require more servings per day of certain food groups, particularly the milk group. Therefore, the adolescent who is pregnant will require more milk servings. The other clients do not require more servings of milk.
The nurse is providing education to a client with high triglyceride and cholesterol levels. Which food should the client be cautioned to avoid?
coconut Explanation: Coconut oil, palm oil, and palm kernel oil are highly saturated fats.
The nurse is teaching a client about ways in which to reduce sodium in the diet. Which foods will the nurse recommend that the client avoid? Select all that apply.
cured ham table salt bacon Explanation: Sodium is found in higher concentrations in table salt, bacon, and processed meats. The other choices do not have a high concentration of sodium.
A woman consumes pasta, grains, and other carbohydrates for which purpose?
energy Explanation: The main function of carbohydrates is to provide energy.
A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to:
fluid and electrolyte levels. Explanation: Total parenteral nutrition (TPN) is nutrition administered through a central venous access and is high in nutrients and electrolytes. It is important to assess fluid and electrolyte levels with TPN infusions. Falls are a risk associated with ability to reposition and not TPN. There is no pain associated with TPN infusions as the medication is administered via a central venous access line. Nausea or vomiting are not adverse effects associated with TPN as the medication is administered via a central line and not by a feeding tube in the stomach.
A client who follows a vegetarian diet should include which foods to maintain a healthy diet?
legumes and vegetables Explanation: The vegetarian diet or vegan includes only foods from plants: fruits, vegetables, legumes (dried beans and peas), grains, seeds and nuts. Red meats are not part of a vegetarian diet. Chocolate, wine, and processed white bread would not be considered to be healthy choices for a vegetarian diet.
A client has developed an abscess following abdominal surgery, and the client's food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support?
low prealbumin levels Explanation: Prealbumin levels are a good indicator of a client's short-term nutritional status; decreased levels are suggestive of malnutrition. Protein in the client's urine, low blood sugars, and increased white blood cells are not necessarily indicative of malnutrition. Proteinuria is urine having an abnormal amount of protein. The condition is often a sign of kidney disease. Random blood sugar can be affected by food intake. White blood cells are indicative of infection.
An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of:
negative nitrogen balance. Explanation: A negative nitrogen balance exists when excretion of nitrogen exceeds the intake.
A client who is taking supplements reports severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely:
niacin. Explanation: Niacin, part of the B vitamins, has a known side effect of flushing and itching after ingestion. The other vitamins that make up the B complex vitamin are B1 thiamin, B2 riboflavin, B3 niacin, B5 pantothenic acid, B6 pyridoxine, B7 biotin, B9 folic acid, and B12 cobalamin. Other adverse effects of the B complex vitamins include nausea, vomiting, constipation, abdominal pain, and black stools.
A 45-year-old client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with the morning labs and the result is 99.10 mg/dL (5.5 mmol/L). How would the nurse interpret this blood glucose?
normal Explanation: Normal blood glucose is 80 to 110 mg/dL (4 to 7 mmol/L).
The community nurse is educating client groups about nutrition. Which group does the nurse identify that will benefit most from nutritional counseling and intervention?
older adults living on a fixed income Explanation: Older adults who are socially isolated or living on fixed incomes will benefit most from nutritional counseling and intervention. Other individuals are not at the same level of risk.
A nurse is working with a 45-year-old construction worker. The nurse obtains his height and weight and calculates that his BMI is 28. How would the nurse best classify James?
overweight Explanation: A body mass index (BMI) between 25 and 29.9 is considered overweight.
A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?
overweight Explanation: A client with a BMI below 18.5 should be considered underweight. A client with a BMI of 18.5 to 24.9 is considered to be at a healthy weight. A client with a BMI of 25 to 29.9 is considered overweight; a client with a BMI of 30 or greater indicates obesity. A BMI greater than 40 is considered extreme obesity.
The nurse is educating a client with chronic anemia about their recommended diet. What will the nurse include in the teaching?
red meat Explanation: Red meat is a source of iron. It therefore should be included in the diet of a client with chronic anemia. Dairy products, citrus fruits, and yellow vegetables are nutrient-dense foods, but they are not sources of iron. Dairy products are sources of fat, whereas citrus fruits and yellow vegetables are sources of vitamins.
A nurse teaches a student nurse about the role fats play in the human body. What is the major storage form of fat?
triglycerides Explanation: Triglycerides are the predominant form of fat in food and the major storage form of fat in the body, composed of one glyceride molecule and three fatty acids. Trans fat is a product that results when liquid oils are partially hydrogenated. These oils then become more stable and solid. Trans fats raise serum cholesterol levels. Cholesterol is a fat-like substance, found only in animal tissues, which is important for cell membrane structure, a precursor of steroid hormones and a constituent of bile. Lipid is a group name for fatty substances, including fats, oils, waxes, and related compounds.
A 16-year-old adolescent informs her nurse that she became a vegetarian 1 year ago. Lately she is reporting fatigue and has trouble concentrating. A quick blood test ordered by her licensed provider informs the nurse that she has pernicious anemia. This is a deficiency of what vitamin?
vitamin B12 Explanation: Vitamin B12 deficiency is most commonly found in vegetarians, particularly in strict vegans. Individuals who have such rigid dietary restrictions must take care to supplement this vitamin.
Which vitamin is found only in animal foods?
vitamin B12 Explanation: Vitamin B12 functions in the formation of mature red blood cells and in synthesis of DNA and RNA. This vitamin is only found in animal foods (meats, fish, poultry, milk, and eggs).
A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect?
vitamin D Explanation: Severe vitamin D deficiency manifests as rickets, osteomalacia, poor dentition, and tetany.