Chapter 13: Nutritional Assessment

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

Chronic dieting

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

End stage renal disease

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

Green, leafy vegetables

A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and 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

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

A nurse is assessing the nutritional status of an elderly client. Which of the following tools would be best for the nurse to use for this client?

Mini nutritional assessment (MNA-SF)

Which statement about overnutrition should a nurse keep in mind when evaluating a client's nutritional status?

Muscle, bone, Fat, and fluid can account for excessive weight

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 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

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

A nurse has just determined a client's BMI. Which measurement should the nurse add to the BMI to increase the predictive ability for health risk to the client?

Waist circumference

A nurse is measuring an adult male client's mid-arm circumference as part of the overall assessment of the client's nutritional status. Which of the following is the standard reference for the MAC for an adult male?

29.3 26.3 lowest point for male 25.7 malnourished female 28.5 standard for female

How can a nurse best assess a client's dietary habits?

Obtain a 24 hour dietary recall of all foods and fluids consumed

A nurse obtains a height measurement on an elderly client and notes that the height has decreased from 5 years ago. What is an appropriate action by the nurse?

Record this measurement in the client and alert the health care provider

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

"I drink two large bottles of caffeinated beverages every day."

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

-A single mother of three who makes 20,000 per year -A 12-year old girl with Crohn's disease -A 33 year old smoker who says that food has lost its taste -A teenage girl who typically snacks on carrots and apple slices -An elderly woman with Alzheimer's disease

A nurse is assessing a client who is obese, gathering subjective data. Which subjective questions regarding nutritional status are appropriate for the nurse to ask this client? Select all that apply.

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

A nurse is assessing a client's nutrition. Which of the following would best assist in assessing client's dietary habits? Select all that apply.

-Assess for the presence of any chronic illnesses that affect intake or absorption of nutrients -Ask about how much food is eaten at an average meal

A home health care nurse is instructing an elderly client on nutrition and health. Which of the following measures should the nurse mention as methods of ensuring food safety? Select all that apply.

-Cleaning lettuce before chopping it up for a salad -Using a meat thermometer to ensure that a turkey is fully cooked -Separating raw from cooked ground beef to prevent cross-contamination

What are appropriate dietary instructions that a nurse should provide to a client who is overweight? Select all that apply.

-Consume calcium-rich foods -Choose lean protein sources -Make half your grains whole

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

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.

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

A nurse is assessing the hydration status of a young client with a hight temperature. Which interventions should the nurse implement in this case? Select all that apply.

-Observe skin moisture -Check turgor -Palpate radial pulse -Inspect tongue condition

A nurse begins a comprehensive physical examination on a client and notes that the client has a large amount of adipose tissue around the waistline. The nurse recognizes that this client should be assessed for an increased risk of which diseases? Select all that apply.

-Type 2 diabetes mellitus -Stroke -Hypertension

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

19

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