exam 2

A client is discussing weight loss with a nurse. The patient says, "I will not eat for two weeks, then I will lose at least 10 pounds." What should the nurse tell the client?

"That will decrease your metabolic rate and make weight loss more difficult."

A nurse is feeding a client. Which of the following statements would help a person maintain dignity while being fed?

"What part of your dinner would you like to eat first?"

Which of the following nutritional guidelines should a nurse provide to a client who is entering the second trimester of her pregnancy?

"You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients."

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 patients ideal weight?

145 lb

At what percent of weight over ideal weight is a person considered obese?

20%

A nurse performing a nutritional assessment determines BMI of a 5-foot 11-inch male patient who weighs 180 pounds. What would be the BMI for this patient?

25.1

A nurse performing a nutritional assessment determines that the BMI of a 5'11" (1.8 meters) male client who weighs 81 kilograms is which of the following?

25.1

A nurse is helping a client design a weight-loss diet. To lose one pound of fat (3,500 calories) per week, how many calories should be decreased each day?

500

A nurse is helping a patient design a weight-loss diet. To lose 1 pound of fat (3,500 calories) per week, how many calories should be decreased each of the 7 days of the week?

500

A client is interested in losing 15 pounds, and she informs the nurse she is counting her calorie intake each day. The client has a goal of losing one pound a week until she reaches her goal. The client asks the nurse how many calories she should decrease daily to lose a pound a week. What is the nurse's best response?

500 calories/day

For which of the following clients should the nurse anticipate the need for a pureed diet?

A man whose stroke has resulted in difficulty swallowing

Which client will have an increased metabolic rate and require nutritional interventions?

A person with a serious infection and fever

The lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the a) cilia. b) alveolar sacs. c) bronchioles. d) alveolar ducts.

A) cilia

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first? a) A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min b) A 57-year-old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence c) A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min d) A 23-year-old woman who had a mountain biking accident in which she suffered a neck fracture and now has numbness and tingling in her right arm

A)A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min

A nurse cares for a client admitted after falling off a ladder onto a concrete floor. The client is not arousable and pupils are fixed and dilated. When performing a respiratory assessment, the nurse recognizes which breathing pattern as normal for clients with brain damage? a) Biot's b) Cheyne-Stokes c) Kussmaul's d) Retractive

A)Biot's

Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process? a) Chronic obstructive pulmonary disease b) Pneumothorax c) Carcinoma of the lungs d) Tuberculosis

A)Chronic Obstructive Pulmonary Disease

The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include? a) Evaluate changes in respiratory pattern and rate. b) Review blood work including RBC and WBC. c) Assess for signs of nonproductive cough. d) Assess the characteristics of sputum

A)Evaluate changes in respiratory pattern and rate

What would the nurse expect to hear when auscultating the lungs of a client with pleuritis? a) Friction rub b) Stridor c) Sibilant wheeze d) Decreased breath sounds

A)Friction rub

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? a) Instruct the client to cough forcefully b) Listen again with the bell of the stethoscope c) Have the client breathe through the mouth d) Assess for the use of accessory muscles

A)Instruct the client to cough forcefully

A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect? a) Severe brain damage b) Diabetic ketoacidosis c) Narcotic overdose d) Renal failure

A)Severe brain damage

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? a) Stridor b) Rales c) Wheezes d) Crackles

A)Stridor

The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation? a) Teaching strategies to reduce complications of existing diagnoses b) Encouraging adequate rest c) Showing participants how to diagnose respiratory problems d) Reinforcing the need for a high-calorie diet

A)Teaching strategies to reduce complications of existing diagnoses

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus? A. Cream of broccoli soup with whole wheat crackers and tapioca for dessert B. Hamburger on soft roll with a side salad and an apple for dessert C. Low-fat turkey chili with sour cream and fresh pears for dessert D. Chicken salad on toast with tomato and lettuce and honey bun for dessert

A. Cream of broccoli soup with whole wheat crackers and tapioca for dessert

Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) A. Patient's weight B. Patient's level of cooperation C. Patient's ability to assist D. Presence of medical equipmentE. 24-hour calorie intake

A. Patient's weightB. Patient's level of cooperationC. Patient's ability to assistD. Presence of medical equipment

A client visits a health care facility with complaints of loss of appetite following a prolonged illness. How should the nurse document the client's condition?

Anorexia

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what? a) Tachypnea b) Bradypnea c) Hypoventilationd ) Hyperventilation

B) Bradypnea

A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data? a) Impaired Gas Exchange b) Ineffective Airway Clearance c) Ineffective Breathing Pattern d) Risk for Respiratory Infection

B)Ineffective Airway Clearance

When performing a physical examination for a client with scoliosis, which physical characteristic should the nurse expect to find during the assessment? a) Exaggerated curvature of the thoracic vertebrae b) Lateral deviation of the spinous processes c) Shoulders and scapulae at a horizontal position d) Non-protruding, symmetrical scapulae

B)Lateral deviation of the spinous processes

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation? a) Percuss to determine diaphragmatic excursion b) Observe for the use of accessory muscles c) Auscultate for the presence of crackles d) Palpate for tactile fremitus

B)Observe for the use of accessory muscles

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse? a) Report this to the health care provider immediately b) Observe the client's respiratory rate and pattern c) Ask the client how long they have to rest between activities d) Assess for symmetry of chest expansion

B)Observe the client' respiratory rate and pattern

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse? a) Ask the client how long they have to rest between activities b) Observe the client's respiratory rate and pattern c) Assess for symmetry of chest expansion d) Report this to the health care provider immediately

B)Observe the client's respiratory rate and pattern

Which action by a nurse demonstrates proper technique for assessment of chest expansion? a) Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest b) Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath c) Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall d) Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest

B)Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath

Which of the following occurs in respiratory distress? a) Neck muscles are relaxed .b) Skin between the ribs moves inward with inspiration. c) The client speaks in sentences of 10-20 words. d) Client torso leans posteriorly.

B)Skin between the ribs moved inward with inspiration

The apex of each lung is located at the a) level of the sixth rib b) area slightly above the clavicle. c) left oblique fissure. d) level of the diaphragm.

B)area slightly above the clavicle.

The patient at greatest risk for developing multiple adverse effects of immobility is a: A. 1-year-old child with a hernia repair. B. 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA). C. 51-year-old woman following a thyroidectomy. D. 38-year-old woman undergoing a hysterectomy.

B. 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA).

Which is an outcome for a patient diagnosed with osteoporosis? A. Maintain serum level of calcium. B. Maintain independence with activities of daily living (ADLs). C. Reduce supplemental sources of vitamin D. D. Reverse bone loss through dietary manipulation.

B. Maintain independence with activities of daily living (ADLs).

An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)A. B/P = 128/84B. Respirations 26 per minute on room airC. HR 114D. Crackles heard on auscultationE. Pain reported as 3 on scale of 0 to 10 after medication

B. Respirations 26 per minute on room airC. HR 114D. Crackles heard on auscultation

A patient of any age can develop a contracture of a joint when: A. The adductors muscles are weakened as a result of immobility. B. The muscle fibers become shortened because of disuse. C. The calcium-to-phosphorus ratio becomes disrupted. D. There is a deficiency in vitamin D.

B. The muscle fibers become shortened because of disuse.

A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.) A. The rubber mat in the walk-in shower B. The three-legged stool on wheels in the kitchen C. The braided throw rugs in the entry hallway and between the bedroom and bathroom D. The night-lights in the hallways, bedroom, and bathroomE. The cordless phone next to the patient's bed

B. The three-legged stool on wheels in the kitchenC. The braided throw rugs in the entry hallway and between the bedroom and bathroom

Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.) A. Repositioning patient every 1 to 2 hours while awake B. Using an objective, valid scale to assess patient's risk for pressure ulcer development C. Using a device to relieve pressure when patient is seated in chair D.Teaching patient how to shift weight at regular intervals while sitting in a chairE. A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes

B. Using an objective, valid scale to assess patient's risk for pressure ulcer developmentC. Using a device to relieve pressure when patient is seated in chairD.Teaching patient how to shift weight at regular intervals while sitting in a chairE. A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes

A nurse is discussing infant care with a woman who just had a baby girl. What type of nutrition would the nurse recommend for the infant?

Breast-feeding or formula with iron

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields? a) Tympany b) Hyperresonance c) Resonance d) Dullness

C) Resonance

A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes? a) Sleep apnea b) Emphysema c) Bacterial infection d) Lung cancer

C)Bacterial Infection

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what? a) Pectoriloquy b) Pigeon chest c) Funnel chest d) Intercostal bulging

C)Funnel chest

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first? a) Auscultate for egophony b) Perform bronchophony c) Have the client cough and then listen again d) Refer the client for further medical evaluation

C)Have the client cough and then listen again

A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition? a) Asthma b) Pneumonia c) Pleurisy d) Rales

C)Pleurisy

A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." Your first action is to: A. Call the health care provider to report this change in condition. B. Give the patient a paper bag to breathe into to decrease her anxiety. C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. D. Explain that this is normal after such trauma and administer the ordered pain medication.

C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to: A. Prevent varicose veins. B. Prevent muscular atrophy. C. Ensure joint mobility and prevent contractures. D. Promote venous return to the heart.

C. Ensure joint mobility and prevent contractures.

Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? A. The patient is 5 feet 6 inches and weighs 120 lbs. B. The patient speaks and understands English. C. The patient received an injection of morphine 30 minutes ago for pain. D. You feel comfortable handling a patient of his size and with his level of cooperation.

C. The patient received an injection of morphine 30 minutes ago for pain.

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, she informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy?

Carbohydrates, protein, and lipids

A nurse is caring for a client with excessive abdominal fat. Which of the following is a risk associated with excessive abdominal fat about which the nurse should inform the client?

Cardiovascular disease

The nurse is testing the blood glucose levels of a client with a history of diabetes. The nurse has performed hand hygiene, checked the order, informed the client and turned on the monitor. After removing a test strip from the vial, the nurse should do which of the following?

Confirm that the strip and the meter share the same code.

While reviewing an adult client's chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information?

Continue with care; this is a normal fluid intake.

While reviewing an adult patients chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information?

Continue with care; this is a normal fluid intake.

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough? a) "Have you changed your diet within the past few weeks?" b) "How much do you exercise during the week?" c) "Do you feel that you are under a great deal of stress?' d) "Are you taking any medications on a regular basis?

D)"Are you taking any medications on a regular basis?"

Which of the following muscles is primarily responsible for thoracic cavity enlargement? a) Sternomastoid b) Parasternal c) Scalene d) Diaphragm

D)Diaphragm

The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include? a) Assess the characteristics of sputum. b) Review blood work including RBC and WBC. c) Assess for signs of nonproductive cough. d) Evaluate changes in respiratory pattern and rate.

D)Evaluate changes in respiratory pattern and rate.

A patient with left-sided weakness asks his nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be your best therapeutic response? A. "Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you." B. "Would you like me to walk on your right side so you feel more secure?" C. "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side." D. "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.

D. "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education? A. "I usually go swimming with my family at the YMCA 3 times a week." B. "I need to ask my doctor if I should have a bone mineral density check this year." C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. "

D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. "

A patient had a left-sided cerebrovascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? A. Pale yellow urine B. Unilateral neglect C. Slight movement noted on the R side D. Coffee ground-like aspirate from the feeding tube

D. Coffee ground-like aspirate from the feeding tube

An older adult who was in a car accident and fractured his femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time? A. Chronic pain B. Impaired skin integrity C. Risk for ineffective cerebral tissue perfusion D. Risk for activity intolerance

D. Risk for activity intolerance

To promote health of the fetus, the nurse should instruct the woman in the first trimester of pregnancy to do which of the following?

Eat foods high in folic acid

A nurse is teaching a young mother about meal preparation for good nutrition. What is one recommendation of the MyPyramid Food Guide?

Eat whole-grain foods with meals.

The nurse caring for a client for several days has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake?

Encourage his daughter to prepare food at home and bring it to the client.

What independent nursing intervention can be implemented to stimulate appetite?

Encourage or provide oral care.

How often would a nurse recommend a client eat or drink a source of vitamin C?

Every day

Which of the following are signs and symptoms of poor nutritional status?

Flaky facial skin, facial edema, pale skin color

Which of the following factors increase BMR? Select all that apply.

Growth, Infections, Fever, Emotional tension

Most nutritionists recommend increasing fiber in the diet. In addition to other benefits, how does fiber affect cholesterol?

Increases fecal excretion of cholesterol

What information do anthropometric measurements provide in adults?

Indirect measure of protein and fat stores

In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate?

Infection

What is the route of administration for TPN?

Intravenous

A client has been prescribed a clear liquid diet. What food or fluids will be served?

Jell-O, carbonated beverages, apple juice

A patient has been prescribed a clear liquid diet. What food or fluids will be served?

Jell-O, carbonated beverages, apple juice

A nurse has documented that a client has anorexia. What does this term mean?

Lack of appetite

A nurse is caring for a young adult female client who has a folic acid defiency. When teaching the client about this condition, the nurse would include a discussion about the client's increased risk for which of the following?

Neural tube deficits in the fetus

A nurse has assessed the residual amount before beginning a nasogastric tube feeding and has found 100 mL. What will the nurse do next?

Nothing; this amount is within normal limits.

A nutritionist helps to plan a diet for a client with diabetes. Which of the following foods is a carbohydrate that should be included to help improve glucose tolerance?

Oatmeal

What best defines ideal body weight (IBW)?

Optimal weight for optimal health

A nurse calculates the BMI of a client during a general survey as 26. Under which of the following categories would this client fall?

Overweight

A hospitalized client has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition?

Poor wound healing, apathy, edema

A nurse researching a diet for a client with diabetes includes foods that supply energy to the body. Which of the following are classes of nutrients that supply this energy? Select all that apply.

Proteins, Fats, Carbohydrates

Which of the following laboratory results indicates the presence of malnutrition?

Serum albumin 2.8 g/dL

A nurse is caring for a client with complaints of chest pain. Which of the following test results would indicate whether the client is at risk for cardiac disease?

Test results for dyslipidemia

A student is following current recommendations for assessing tube placement. A staff nurse says, Oh, just insert air and listen for a whoosh sound. How would the student respond?

That procedure has been found to be unreliable.

A patient is discussing weight loss with a nurse. The patient says, I will not eat for 2 weeks, then I will lose at least 10 pounds. What should the nurse tell the patient?

That will decrease your metabolic rate and make weight loss more difficult.

A nurse is caring for a client with a history of cardiac and vascular disease. Which of the following fats should the nurse allow in the client's diet for his condition?

Unsaturated fats

A nurse is feeding a patient. Which of the following statements would help a person maintain dignity while being fed?

What part of your dinner would you like to eat first?

A nurse is conducting a health history interview for an older adult. Which of the following questions or statements would be important for nutritional assessment?

What prescribed and over-the-counter medicines do you take?

A healthy, active 72-year-old woman asks a nurse if it is safe to take dietary supplements and, if so, what should be taken? What would the nurse tell her?

Yes, take calcium, vitamin D, and vitamin B12.

Which of the following patients will have an increased metabolic rate and require nutritional interventions?

a person with a serious infection and fever

After the administration of a nasointestinal feeding tube, a patient complains of gas, abdominal pain, and dizziness. What do these symptoms indicate?

a type of dumping syndrome

At what period of life do nutrient needs stabilize?

adulthood

How often would a nurse recommend a patient eat or drink a source of vitamin C?

every day

What health problem may occur in a person who is on a low-carbohydrate diet for a long period of time?

ketosis

A nurse has documented that a patient has anorexia. What does this term mean?

lack of appetite

A hospitalized patient has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition?

poor wound healing, apathy, edema

What is the most critical component of an enteral feeding formula?

protein

A nurse researching a diet for a patient with diabetes includes foods that supply energy to the body. Which of the following are classes of nutrients that supply this energy? Select all that apply.

proteins, fats, carbohydrates

Which laboratory test is the best indicator of a patient in need of TPN?

serum albumin