(PrepU) Chapter 13: Assessing Nutritional Status

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 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 recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present?

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.

Which of the following are causes of weight loss? (Mark all that apply.)

Chronic renal failure Chronic infections Adrenal insufficiency Causes of weight loss include gastrointestinal diseases; endocrine disorders (diabetes mellitus, hyperthyroidism, adrenal insufficiency); chronic infections; malignancy; chronic cardiac, pulmonary, or renal failure; depression; and anorexia nervosa or bulimia.

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 Obesity is an excessive fat in relation to lean body mass. The health risks of obesity include diabetes, hypertension, and sleep apnea. Anorexia is a disorder whereby food is self-limited or refused. Cirrhosis is a chronic disease that involves scarring of the liver and may interfere with the absorption or use of nutrients.

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. 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.

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 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.

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 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.

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. The instructor should determine that the teaching was successful when the students identify that malnutrition includes overnutrition and undernutrition. Although height-weight charts are good reference points, they are not the best determinants of malnutrition. Muscle is heavier than fat. The amount of body fat includes concern for both the fat distribution throughout the body and the size of the fat deposits. A thin client may or may not have a low percentage of fat.

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 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 client asks for help with determining the amount and type of foods to consume to improve nutritional intake. What should the nurse recommend that this client use?

My Plate The U.S. Department of Agriculture's (USDA's) Choose My Plate is a tool to help individuals analyze their diet and set goals for a healthier diet. A calorie counter will not necessarily help the client select healthful foods. An 1800 calorie diet may be too much or insufficient to meet the client's nutritional needs. Healthy People 2020 does not provide direction as to how to improve nutritional status.

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 client?

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 client 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 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 Briefly, carbohydrates are referred to as either simple or complex, depending on their chemical structure. Simple carbohydrates, such as found in fruit juice, are sugar with a simple structure that raises the blood glucose level and can be converted quickly into energy. Complex carbohydrates, such as whole grains, are starches that more slowly convert into energy and can also be used as an energy source. Carbohydrates are known as protein sparing because the body uses them for an energy source rather than breaking down proteins to fuel the body's energy needs. Protein and fat can be used as energy sources but are not the body's first source of energy, and are metabolized more slowly.

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 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.

When beginning a height measurement on a 14-year-old, the nurse should instruct the client to stand on the scale with heels together.

True If a scale is available, the nurse should instruct the client to stand shoeless on the scale with heels together and back straight, looking straight ahead. The nurses then should use the L-shaped measuring attachment on the scale to measure height.

The nurse might expect the client admitted with dehydration to have tachycardia.

True Tachycardia, a weak pulse and decreased blood pressure can indicate dehydration, while a bounding pulse and increased blood pressure may mean overhydration.

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 Emphasis of nutritional guidelines is on variety; increased intake of vegetables, fruits, lentils, and grains, particularly from plant sources; and meeting individual nutritional needs while avoiding either deficiencies or excesses in nutrient intake.

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?

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.

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

Waist circumference. Waist circumference is the most common measurement used to determine the extent of abdominal visceral fat in relation to body fat.

A nursing instructor is teaching nursing students how to perform a nutritional assessment, collecting both objective and subjective data. The nursing instructor determines understanding of the differences between objective and subjective findings when the students identify which of the following as subjective data?

health history interview Nutritional assessment is composed of nutritional screening and a comprehensive nutritional assessment that includes collection of subjective data through a health history interview. Objective data include anthropometric measurements used to evaluate the client's physical growth, development, and nutritional status (including height and weight) as well as laboratory tests.

A client has a body mass index of 26.5. What teaching would be indicated for this client?

reduce caloric intake by 250-500 calories each day The client's BMI is 26.5 which is approximately 7-8 lbs. over ideal BMI. By reducing caloric intake by 250-500 calories each day, the excess weight can be lost. There is no reason to eliminate one food group from the diet. This could lead to nutritional disorders. Increasing the caloric intake by 300 calories each day would cause the client to gain weight. There is no need to suggest medication to aid with weight reduction because the amount of weight to lose is not extreme.

The nurse is collecting a health history for a client with signs and symptoms of dehydration. Which factors should be considered as contributing to this problem? Select all that apply.

use of a walker to ambulate environmental temperature 42 degrees Celsius the previous day presence of painful sores in the mouth Excessive heat, decreased mobility, and inability or lack of desire to drink due to painful mouth sores would lead to dehydration. The presence of liver disease and eating increased sodium, such as that in foods like french fries and potato chips, can cause overhydration.

Because BMI is calculated using only height and weight, the nurse knows that inaccurate findings would most likely occur in a client

who is a bodybuilder. The use of BMI alone is not diagnostic of a client's health status. Because BMI does not differentiate between fat or muscle tissue, inaccurately high or low findings can result for people who are particularly muscular or for older adults who tend to lose muscle mass.

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

A

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

Absence of menstrual periods 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 triage nurse suspects malnutrition in an older adult with altered mental status who has been brought to the emergency department by family members. What visible signs might the nurse have noticed that would lead to the suspicion of malnutrition? Select all that apply.

Atrophied tongue Temporal muscle wasting Generalized muscle weakness Dry eyes Clinical findings of malnutrition can occur throughout the body. Visible signs include muscle wasting, particularly in the temporal area; muscle weakness and decreased muscle size; tongue atrophy; and bleeding or changes in the integrity or hydration status of the skin, hair, teeth, gums, lips, tongue, eyes, and, in men, genitalia. A productive cough is not a visible sign of malnutrition.

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 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.

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 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 74-year-old man has been taking a beta-blocker for several years, and his care provider has chosen to add a diuretic to his regimen to better control his hypertension. What should the clinician teach the client about the relationship between his new medication and his nutritional health?

"This will make you urinate more often, so make sure you drink plenty of fluids." Diuretics are associated with reduced fluid intake; clients should thus be encouraged to maintain and monitor their daily fluid intake. Constipation, nausea, and iron-deficiency are not associated with diuretic use.

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?

"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.

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." 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.

A female client with a diagnosis of hypothyroidism asks the nurse why she has begun to gain body weight. Which is the best explanation the nurse can provide?

"Your metabolism is slowing down." The pituitary gland is responsible for the release of thyroid stimulating hormone (TSH). Due to the decreased production of TSH in hypothyroidism, the metabolism slows down resulting in weight gain. Weight gain associated from hypothyroidism is not as a result of fluid retention, though this can be a secondary cause for additional weight gain. Although making healthy food choices and encouraging exercise are important to discuss with any client, these responses do not sufficiently explain this phenomenon.

To calculate the ideal body weight for a woman, the nurse allows

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.

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 client's ideal weight?

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

19 BMI The BMI is calculated by dividing weight in pounds by height in inches squared, multiplied by 703. The body mass index calculated by the nurse should be 19 for a client who is 5 feet 5 inches tall (65 inches). 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 body mass index, which can be calculated regardless of the client's gender.

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 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 24.4 for a client who is 5 feet 11 inches tall and 175 pounds.

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

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.

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 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.

When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet?

5 When calculating ideal body weight for women, add 5 pounds for each additional inch over 5 feet. The other numerical values are incorrect.

A nurse is caring for several clients in an outpatient setting. Which of the following clients is most likely to experience a weight gain?

A 33-year-old athlete on steroids A client taking steroids may gain weight.

The healthcare provider states that the client's blood count with differential demonstrates a shift to the left. The nurse expects to see which lab result when reviewing the differential?

Bands greater than 10% A differential indicates the various white blood cell types. Bands are granulocytes or immature white blood cells. An increased percentage indicates infection.

The nurse should perform which priority assessment on a client with a history of a high hydrogenated fat intake?

Cardiac The cardiac assessment is of priority concern for this client. Foods made with hydrogenated fats are particularly harmful to the diet because they are the largest contributors of trans fats. Empirical evidence suggests that trans fats are as damaging to the heart and blood vessels as saturated fats (Mente de Koning, Shannon, and Anand, 2009).