Chapter 5: Adult Health and Nutritional Assessment Prep-U

A nurse determines that a male patient has an increased risk for diabetes, heart disease, and hypertension based on the patient's waist circumference. Which waist circumference measurement would lead the nurse to suspect this?

41 inches

The nurse observes a serum albumin level of 2.50 g/dL in an older adult patient who lives at home alone. What does this level indicate?

A severe protein deficiency

A hospice nurse is discussing spirituality and faith with a client and the client's family member. The client asks the nurse what is the difference between spirituality and faith. How will the nurse describe faith?

"A trust and belief in a higher power or something you cannot see"

Nursing students are reviewing information about the MyPyramid recommendations for food intake. The students demonstrate a need for additional review when they identify which of the following as one of the five major food groups?

Fats

A female patient comes to the clinic for evaluation. As part of the assessment, the nurse determines the patient's ideal body weight. The patient is 5' 5" tall and has an average frame. What would be her ideal body weight in lbs? Enter the correct number only.

125

A nurse is preparing a teaching plan based on MyPyramid recommendations to promote healthy nutrition for an adult. The nurse would recommend a daily milk intake of how many cups?

3

An individual is considered obese when their BMI is what value?

30-39

A positive nitrogen balance indicates which condition?

Tissue growth

When obtaining a health history from an older adult patient, what should the nurse remember to do? (Select all that apply.)

Ask questions slowly, directly, and in a voice loud enough to be heard by those who are hearing impaired. Clarify the frequency, severity, and history of signs and symptoms of the present illness. Conduct the interview in a calm, unrushed manner using eye-to-eye contact.

While collecting the client profile information, the client admits to crying everyday after working 8 hours in a factory. This finding reflects what part of the profile?

Coping strategies

Which statement by the nurse reflects the nurse's attempt to establish rapport and reduce patient anxiety?

"Good morning, Mr. Jones. The last time you were here you were planning a vacation. Tell me about your trip."

Which statement made by the nurse indicates that the nurse is performing a holistic health history versus a traditional health or medical history?

"How has the stroke affected your ability to perform your daily activities?"

A graduate nurse is completing her first health history questionnaire with a client. She needs to assess the client's sexual history at the end of the interaction. Which opening remark for this topic would be most appropriate?

"Lastly, I need to ask about your sexual health and practices."

A nurse cares for an older adult client who is taking over ten different medications or supplements. What statement made by the nurse best assesses the client for medication interactions?

"Can you please tell me what each of your medications are for?"

Which question asked by the nurse will provide information about a patient's lifestyle? (Select all that apply.)

"Do you have any food preferences?" "How many hours of sleep do you require each day?" "What type of exercise do you prefer?"

Two nursing students are role-playing a patient assessment situation. One of the students is acting as the nurse, and the other student is acting as the patient. The task is to focus on assessing the patient's lifestyle. Which question would be most appropriate for the student acting as the nurse to ask?

"What do you usually do for fun?"

A waist circumference greater than which value is indicative of excess abdominal fat in men?

101.60 cm (40 in)

To calculate the ideal body weight for a woman, the nurse allows for which of the following?

100 lb for 5 ft of height

The nurse working in a culturally diverse neighborhood knows that providing culturally sensitive materials during nutritional counseling will increase client understanding of the nutritional information. What is the best way for the nurse to prepare materials for the client in order to provide culturally appropriate teaching?

Access a government-sponsored website that provides culturally appropriate food guides.

A nurse is preparing a presentation for a group of adolescent girls about nutritional risks at this life stage. When developing this presentation, the nurse integrates knowledge about which of the following?

Adolescent girls usually do not consume enough foods that are high in iron.

What primary nutritional nursing consideration should be included in the physical assessment of an older adult patient?

Altered metabolism and nutrient use secondary to an acute or chronic illness

A nurse is conducting a physical assessment of a patient with a cardiac murmur. Which technique would the nurse most likely use to assess the murmur?

Auscultation

A nurse determines that a patient has poor nutrition based on which assessment finding?

Beefy-red tongue

A patient arrives at the clinic for an evaluation. This is the first time the patient is being seen. Which information would the nurse need to obtain first?

Biographical data

A nurse is obtaining family history from a patient. Which of the following would be LEAST helpful to use when documenting this information?

Checklist

A nurse is conducting a health history with a patient and has obtained the necessary biographical information. The nurse then collects data from the patient in the following categories. Place the categories in the proper sequence for data collection.

Chief complaint (reason for seeking care) Present health concern Past health history Family history Review of systems

A community health nurse goes on a first home visit to complete a home safety assessment. Which of the following components will be part of the nurse's home safety assessment? Select all that apply.

Hard wood floors in the dining room Motion light on the porch ABC fire extinguisher in the kitchen pantry

What priority factor regarding the patient may help the physician arrive at a diagnosis?

History of the present illness

When preparing to perform a physical assessment of a patient, the nurse performs the steps below. Place the steps in the order in which they most typically are completed.

Inspection Palpation Percussion Auscultation

Hyperresonance is audible when which area is percussed?

Overinflated lung tissue

Which element is considered the "fifth vital sign"?

Pain

A male client in a wheelchair comes in for his yearly physical examination. He is unable to stand. The nurse retrives the wheelchair scale to obtain an accurate weight. The nurse understands the importance of this assessment with this client. What is the nurse's reasoning for obtaining an accurate weight?

People with disabilities have an increased incidence of obesity.

The nurse notes hyperresonance over inflated lung tissue when performing a physical assessment on a patient with emphysema. What process does the nurse use for this assessment?

Percussion

When assessing a client who has a draining wound, the nurse would be alert for which of the following nutritional consequences? Select all that apply.

Protein loss Electrolyte loss Mineral loss

The nurse using the assessment technique depicted in the accompanying image realizes that the following factor most strongly influences the success of the results:

Quick striking

A very thin woman seeks medical care. During assessment of this client, the nurse determines the need for a nutritional assessment. Which of the following components will the nurse include in this assessment? Select all that apply.

Ratio of body weight and height Oral mucosa Thyroid gland

A client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination. When percussing the client's chest wall, the nurse expects to elicit:

Resonant sounds

The nurse is preparing the client file for an 8-year-old child. The child's mother informs the nurse that the child has difficulty breathing at night and makes a whistling sound while sleeping. Because of the child's age, her mother continues to provide the child's health history to the nurse. Which action by the nurse demonstrates that the nurse understands the importance of collecting a client's health history?

The nurse continues to collect information from the child's mother, knowing the informant will not always be the client

Which of the following diagnositic findings is indicative of a protein defiency in adults?

low serum albumin.