Health Assessment Exam 2 - Practice Questions

30. In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find?

B) Inadequate nutrient food intake

8. The nurse is reviewing a patient's nutritional assessment. Which statement is true concerning the nutritional assessment?

B) It identifies patients who are at risk of malnutrition.

16. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors ismost likely to affect the nutritional status of an elderly person?

B) Living alone on a fixed income

43. An elderly patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patient's gums are swollen, ulcerated, and bleeding in some areas. The nurse suspects that the patient has what condition?

D) Vitamin C deficiency

23. The nurse is measuring a patient's frame size. Which of these statements best describes the correct technique for measuring frame size?

D) With the right arm extended forward and the elbow bent, use the calipers to measure the distance between the condyles of the humerus.

14. The nurse is performing a nutritional assessment on a 15-year-old girl, who tells the nurse that she is "so fat." Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurse's appropriate response would be:

A) "How much do you think you should weigh?"

29. Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? a. "It should fall off in 10 to 14 days." b. "It will soften before it falls off." c. "It contains two veins and one artery." d. "Skin will cover the area within 1 week."

A) "It should fall off by 10 to 14 days." At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton jelly. The umbilical stump dries within a week, hardens, and falls off in 10 to 14 days. Skin will cover the area in 3 to 4 weeks.

25. The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk?

A) 29-year-old woman whose waist is 33 inches and whose hips are 36 inches

1. The nurse recognizes that which of these persons is at greatest risk for undernutrition?

A) 5-month-old infant

34. The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? a. Blacks b. Hispanics c. Whites d. Asians

A) Blacks A recent study found estimates of lactose-intolerance prevalence as follows: 19.5% for Blacks, 10% for Hispanics, and 7.72% for Whites.

12. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

A) Certain drugs can affect the metabolism of nutrients.

1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Dullness b. Tympany c. Resonance d. Hyperresonance

A) Dullness The liver is located in the right upper quadrant and would elicit a dull percussion note.

30. Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d. Tympany in the right and left lower quadrants

A) Dullness across the abdomen A large amount of ascitic fluid produces a dull sound to percussion.

3. The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group?

A) It is important to maintain adequate fat and caloric intake.

18. If a 29-year-old woman weighs 156 pounds and the nurse determines her ideal body weight to be 120 pounds, how would the nurse classify the woman's weight?

A) Obese

33. When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a. Spleen b. Sigmoid colon c. Appendix d. Gallbladder

A) Spleen The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant.

11. The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status?

A) The absorption of nutrients may be impaired.

36. During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to: a. Enlarged liver. b. Enlarged spleen. c. Distended bowel. d. Excessive diarrhea.

A) an enlarged liver. The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.

19. A nurse notices that a patient has ascites, which indicates the presence of: a. Fluid. b. Feces. c. Flatus. d. Fibroid tumors.

A) fluid. Ascites is free fluid in the peritoneal cavity and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

17. When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include:

A) height and weight.

24. In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of:

A) height and weight.

28. After completing a diet assessment on a 30-year-old woman, the nurse suspects that she may be deficient in iron. Laboratory studies to obtain to verify this condition would be:

A) hemoglobin and hematocrit.

24. During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by: a. Projectile vomiting. b. Hypoactive bowel activity. c. Palpable olive-sized mass in the right lower quadrant. d. Pronounced peristaltic waves crossing from right to left.

A) projectile vomiting. Significant peristalsis, together with projectile vomiting, in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant.

32. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include:

A) slowed gastrointestinal motility.

Which of the following statements best describes the mechanism(s) by which venous blood returns to the heart? 1. Intraluminal valves ensure unidirectional flow toward the heart. 2. Contracting skeletal muscles milk blood distally toward the veins. 3. The high-pressure system of the heart helps to facilitate venous return. 4. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

ANS: 1 Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow.

Which of the following situations best describes a person at risk for development of venous disease? 1. A woman in her fifth month of pregnancy 2. A person who has been on bed rest for 4 days 3. A person with a 30-year, 1 pack per day smoking history 4. An elderly person taking anticoagulant medication

ANS: 2 At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable states and vein wall trauma also place the person at risk for venous disease.

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding would the nurse expect to note? 1. Excessive swelling of the lymph nodes 2. The presence of palpable lymph nodes 3. No nodes palpable because of the immature immune system of a child 4. Fewer numbers and a decrease in size of lymph nodes compared with those of an adult

ANS: 2 Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.

Which of the following statements regarding the lymphatic system is true? 1. Lymph flow is propelled by the contraction of the heart. 2. The flow of lymph is slow compared with that of the blood. 3. One of the functions of the lymph is to absorb lipids from the biliary tract. 4. Lymph vessels have no valves, so there is a free flow of lymph fluid from the tissue spaces into the bloodstream and back again.

ANS: 2 The flow of lymph is slow compared with that of the blood.

A 35-year-old man is seen in the clinic for an "infection in my left foot." Which of the following would the nurse expect to find during an assessment of this patient? 1. Hard and fixed cervical nodes 2. Enlarged and tender inguinal nodes 3. Bilateral enlargement of the popliteal nodes 4. "Pellet-like" nodes in the supraclavicular region

ANS: 2 The inguinal nodes in the groin drain most of the lymph of the lower extremity. With local inflammation, the nodes in that area become swollen and tender.

Which of the following statements is true regarding the arterial system? 1. Arteries are large-diameter vessels. 2. The arterial system is a high-pressure system. 3. The walls of arteries are thinner than those of veins. 4. Arteries can expand greatly to accommodate a large blood volume increase.

ANS: 2 The pumping heart makes the arterial system a high-pressure system.

A 65-year-old patient is experiencing pain in his left calf when he exercises, which disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with: 1. venous obstruction of the left leg. 2. claudication due to venous abnormalities in the left leg. 3. ischemia caused by partial blockage of an artery supplying the left leg. 4. ischemia caused by complete blockage of an artery supplying the left leg.

ANS: 3 Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only at exercise, when oxygen needs increase.

The nurse recognizes that which of the following is a normal physiologic change associated with the aging process? 1. Hormonal changes causing vasodilation and a resulting drop in blood pressure. 2. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency. 3. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure. 4. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities.

ANS: 3 Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure.

The major artery supplying the arm is the: 1. ulnar artery. 2. radial artery. 3. brachial artery. 4. deep palmar artery.

ANS: 3 The major artery supplying the arm is the brachial artery.

A 70-year-old patient is scheduled for open-heart surgery. The physicians plan to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply: 1. "Venous insufficiency is a common problem after this type of surgery." 2. "Oh, we have lots of veins—you won't even notice that it has been removed." 3. "You will probably experience decreased circulation after the veins are removed." 4. "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."

ANS: 4 As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation.

To assess the dorsalis pedis artery, the nurse would palpate: 1. behind the knee. 2. over the lateral malleolus. 3. in the groove behind the medial malleolus. 4. lateral to the extensor tendon of the great toe.

ANS: 4 The dorsalis pedis artery is located on the dorsum of the foot. Palpate just lateral to and parallel with the extensor tendon of the big toe.

When performing an assessment of a patient, the nurse notes the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? 1. Assess the patient's abdomen, noting any tenderness. 2. Carefully assess the cervical lymph nodes, checking for any enlargement. 3. Ask additional history questions regarding any recent ear infections or sore throats. 4. Examine the patient's lower arm and hand, checking for the presence of infection or lesions.

ANS: 4 The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm.

Which of the following veins are responsible for most of the venous return in the arm? 1. Deep veins 2. Ulnar veins 3. Subclavian veins 4. Superficial veins

ANS: 4 The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

1. A patient has been unable to eat solid food for 2 weeks, and is in the clinic today complaining of weakness, tiredness, and hair loss. The patient states that her usual weight is 175 pounds, but today she weighs 161 pounds. What is her recent weight change percentage? To calculate recent weight change percentage, use this formula:

ANS: 8%

31. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? a. "No need to worry. Most men your age develop hernias." b. "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." c. "A hernia is the result of prenatal growth abnormalities that are just now causing problems." d. "I'll have to have your physician explain this to you."

B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall.

11. The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a. "We need to determine the areas of tenderness before using percussion and palpation." b. "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." c. "Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination." d. "Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."

B) "It prevents distortion of bowel sounds that might occur after percussion and palpation." Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

13. A patient tells the nurse that his food just doesn't have any taste anymore. The nurse's best response would be:

B) "When did you first notice this change?"

27. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: a. 1 minute. b. 5 minutes. c. 10 minutes. d. 2 minutes in each quadrant.

B) 5 minutes. Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent.

14. During an abdominal assessment, the nurse would consider which of these findings as normal? a. Presence of a bruit in the femoral area b. Tympanic percussion note in the umbilical region c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line d. Dull percussion note in the left upper quadrant at the midclavicular line

B) A tympanic percussion note in the umbilical region Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally, the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).

31. A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate calories and appears well nourished. In further assessing her, what would the nurse expect to find?

B) Decreased serum albumin

1. The nurse is assessing an obese patient for signs of metabolic syndrome. This condition is diagnosed when three or more certain risk factors are present. Which of these assessment findings are risk factors for metabolic syndrome? Select all that apply.

B) Fasting plasma glucose level greater than or equal to 110 mg/dL C) Blood pressure reading of 140/90 mm Hg

27. The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation?

B) Height measurements may not be accurate because of changes in bone.

44. The nurse is assessing the body weight as a percentage of ideal body weight on an adolescent patient who was admitted for suspected anorexia nervosa. The patient's usual weight was 125 pounds, but today she weighs 98 pounds. The nurse calculates the patient's ideal body weight, and reaches which conclusion?

B) She is experiencing moderate malnutrition.

5. A mother and her 13-year-old daughter express their concern related to the daughter's recent weight gain and increase in appetite. Which of these statements represents information the nurse should discuss with them?

B) Snacks should be high in protein, iron, and calcium.

1. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. a. Test for the Murphy sign b. Test for the Blumberg sign c. Test for shifting dullness d. Perform the iliopsoas muscle test e. Test for fluid wave

B) Test for Blumberg's sign. D) Perform iliopsoas muscle test. Testing for the Blumberg sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. The Murphy sign is used when assessing for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed when assessing for ascites.

28. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test b. Test for Murphy sign c. Assess for rebound tenderness d. Iliopsoas muscle test

B) Test for Murphy's sign Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy test). The person feels sharp pain and abruptly stops midway during inspiration.

23. The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true? a. Abdominal tone is increased. b. Abdominal musculature is thinner. c. Abdominal rigidity with an acute abdominal condition is more common. d. The older adult with an acute abdominal condition complains more about pain than the younger person.

B) The abdominal musculature is thinner. In the older adult, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with an acute abdominal condition is less common in the aging person. The older adult with an acute abdominal condition often complains less about pain than the younger person.

12. The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? a. Are usually loud, high-pitched, rushing, and tinkling sounds. b. Are usually high-pitched, gurgling, and irregular sounds. c. Sound like two pieces of leather being rubbed together. d. Originate from the movement of air and fluid through the large intestine.

B) They are usually high-pitched, gurgling, irregular sounds. Bowel sounds are high-pitched, gurgling, and cascading sounds that irregularly occur from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.

7. During a nutritional assessment of a 22-year-old male refugee, the nurse must remember to:

B) clarify what is meant by the term "food."

17. An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a. Increased gastric acid secretion. b. Decreased gastric acid secretion. c. Delayed gastrointestinal emptying time. d. Increased gastrointestinal emptying time.

B) decreased gastric acid secretion. Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron-deficiency anemia, and malabsorption of calcium.

20. The nurse knows that during an abdominal assessment, deep palpation is used to determine: a. Bowel motility. b. Enlarged organs. c. Superficial tenderness. d. Overall impression of skin surface and superficial musculature.

B) enlarged organs. With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.

39. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a. Examine the tender area first. b. Examine the tender area last. c. Avoid palpating the tender area. d. Palpate the tender area first, and then auscultate for bowel sounds.

B) examine the tender area last. The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

10. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: a. Diarrhea. b. Peritonitis. c. Laxative use. d. Gastroenteritis.

B) peritonitis. Diminished or absent bowel sounds signal decreased motility from inflammation as exhibited with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.

15. The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: a. Diarrhea. b. Pyrosis. c. Dysphagia. d. Constipation.

B) pyrosis. Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct.

41. During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color. This is an indication of _____ deficiency.

B) riboflavin

26. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? a. A bruit is absent. b. Femoral pulses are increased. c. A pulsating mass is usually present. d. Most are located below the umbilicus.

C) A pulsating mass is usually present. Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline.

19. How should the nurse perform a triceps skinfold assessment?

C) After applying the calipers, wait 3 seconds before taking a reading. Repeat the procedure three times.

22. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? a. Spleen b. Sigmoid c. Appendix d. Gallbladder

C) Appendix The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant.

33. Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman?

C) Decrease the number of calories she is eating because of the decrease in energy requirements from loss of lean body mass.

40. During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again!" The nurse suspects that the patient has which condition, based on these symptoms? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis

C) Duodenal ulcer Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may relieved by more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis.

35. A 16-year-old girl is being seen at the clinic for gastrointestinal complaints and weight loss. The nurse determines that many of her complaints may be related to erratic eating patterns, eating predominantly fast foods, and high caffeine intake. In this situation, which is most appropriate when collecting current dietary intake information?

C) Have the patient complete a food diary for 3 days, including 2 weekdays and 1 weekend day.

29. A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic today to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests?

C) Information regarding a diet low in saturated fat

39. Which of these conditions is due to an inadequate intake of both protein and calories?

C) Marasmus

22. The nurse is concerned about the skeletal protein reserves of a patient who has been hospitalized frequently for chronic lung disease. Which of these measurements would be necessary to include in the assessment?

C) Mid-arm muscle area

6. The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find?

C) Osteomalacia

21. When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are evaluated, which is important for the nurse to remember?

C) These measurements may not be accurate because of changes in skin and fat distribution.

37. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? a. Intra-abdominal bleeding b. Constipation c. Umbilical hernia d. Abdominal tumor

C) Umbilical hernia The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.

40. A pregnant woman who is HIV positive is asking the nurse about breastfeeding her infant. Which of these statements is true?

C) Women who are HIV positive should not breastfeed because HIV can be transmitted through breast milk.

3. A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: a. Aphasia. b. Dysphasia. c. Dysphagia. d. Anorexia.

C) dysphagia. Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite.

21. The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: a. Gallbladder disease. b. Overuse of laxatives. c. Gastrointestinal bleeding. d. Localized bleeding around the anus.

C) gastrointestinal bleeding. Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding. Red blood in stools occurs with localized bleeding around the anus.

18. A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of: a. Ovary infection. b. Liver enlargement. c. Kidney inflammation. d. Spleen enlargement.

C) kidney inflammation. Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct.

38. A 65-year-old man is brought to the emergency department after he was found dazed and incoherent, alone in his apartment. He has an enlarged liver and is moderately dehydrated. When evaluating his serum albumin level, the nurse must keep in mind that:

C) low serum albumin levels may be caused by reasons other than protein-calorie malnutrition.

9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: a. Pulsations of the renal arteries. b. Pulsations of the inferior vena cava. c. Normal abdominal aortic pulsations. d. Increased peristalsis from a bowel obstruction.

C) normal abdominal aortic pulsations. Normally, the pulsations from the aorta are observed beneath the skin in the epigastric area, particularly in thin persons who have good muscle wall relaxation.

26. The mother of an 8-year-old boy is concerned about the amount of weight her son has gained. To determine whether this is a problem, the nurse will measure:

C) skinfold thickness.

16. The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a. Flatness, resonance, and dullness. b. Resonance, dullness, and tympany. c. Tympany, hyperresonance, and dullness. d. Resonance, hyperresonance, and flatness.

C) tympany, hyperresonance, and dullness. Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass.

42. A 50-year-old patient has been brought to the emergency department after a housemate found that he could not get out of bed alone. He has lived in a group home for years, but for several months he has not participated in the activities and has stayed in his room. The nurse assesses for signs of under nutrition, and x-rays reveal that he has osteomalacia, which is a deficiency of:

C) vitamin D and calcium.

38. During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: a. Splenomegaly. b. Distended bladder. c. Constipation. d. Ascites.

D) ascites. If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation.

6. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a. The spleen can be enlarged as a result of trauma. b. The spleen is normally felt on routine palpation. c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size. d. An enlarged spleen should not be palpated because it can easily rupture.

D) An enlarged spleen should not be palpated because it can rupture easily. If an enlarged spleen is felt, then the nurse should refer the person and should not continue to palpate it. An enlarged spleen is friable and can easily rupture with overpalpation.

4. A pregnant woman is interested in breastfeeding her baby, and asks several questions about the topic. Which information is appropriate for the nurse to share with her?

D) Breast milk provides the nutrients necessary for growth as well as natural immunity.

36. The nurse is preparing to measure fat and lean body mass and bone mineral density. Which tool is appropriate?

D) Dual-energy x-ray absorptiometry

15. The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of these foods are recommended?

D) Finger foods and nutritious snacks that can't cause choking

10. A patient is asked to indicate on a form how many times he eats a specific food. This would describe which of these methods for obtaining dietary information?

D) Food frequency questionnaire

35. The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem? a. Hypertension b. Streptococcal infections c. Recurrent constipation with frequent laxative use d. Frequent use of nonsteroidal antiinflammatory drugs

D) Frequent use of nonsteroidal anti-inflammatory drugs Peptic ulcer disease occurs with the frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infection.

34. The nurse in a family practice clinic is reviewing the patients scheduled for appointments. Which of these statements is true regarding routine laboratory testing in the following individuals?

D) Laboratory tests for iron and lead levels should be assessed at 9 to 12 months.

9. The nurse is seeing for the first time a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity?

D) Measurement of weight and weight history

4. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region. b. Inspect and palpate in the epigastric region. c. Auscultate and percuss in the inguinal region. d. Percuss and palpate the midline area above the suprapubic bone.

D) Percuss and palpate the midline area above the suprapubic bone. Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.

37. The nurse is reviewing laboratory studies on a patient who may have protein malnutrition. Which of these measurements is an early indicator of protein malnutrition?

D) Serum transferrin

2. Which structure is located in the left lower quadrant of the abdomen? a. Liver b. Duodenum c. Gallbladder d. Sigmoid colon

D) Sigmoid colon The sigmoid colon is located in the left lower quadrant of the abdomen

8. The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile. a. Flat b. Convex c. Bulging d. Concave

D) concave Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane (see Figure 21-7)

32. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm. The nurse should: a. Document the presence of hepatomegaly. b. Ask additional health history questions regarding his alcohol intake. c. Describe this dullness as indicative of an enlarged liver, and refer him to a physician. d. Consider this finding as normal, and proceed with the examination.

D) consider this a normal finding and proceed with the examination. A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.

5. The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: a. Increased salivation. b. Increased liver size. c. Increased esophageal emptying. d. Decreased gastric acid secretion.

D) decreased gastric acid secretion. Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases

13. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: a. Loud continual hum. b. Peritoneal friction rub. c. Hypoactive bowel sounds. d. Hyperactive bowel sounds.

D) hyperactive bowel sounds. Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.

20. To assess the muscle mass and fat stores on a 40-year-old woman, the nurse would use:

D) mid-upper arm circumference.

7. A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: a. Obese. b. Herniated. c. Scaphoid. d. Protuberant.

D) protuberant. A protuberant abdomen is rounded, bulging, and stretched (see Figure 21-7). A scaphoid abdomen caves inward.

2. When assessing a patient's nutritional status, the nurse recalls that the best definition of optimal nutritional status is:

D) sufficient nutrients to provide for daily body requirements and for increased metabolic demands.