NU273 Week 2 PrepU: Assessing Nutritional Status
A teenage client with cancer asks the nurse what hair is made of. What would be the nurse's best answer? "Hair consists mostly of carbohydrates." "Hair consists mostly of protein." "Hair consists mostly of inorganic matter." "Hair consists mostly of cellular waste."
"Hair consists mostly of protein." 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. Chapter 13: Assessing Nutritional Status - Page 234
The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding? "We should review the amount of protein in your diet." "Waist circumference can vary over the course of the day." "Let's discuss your risk factors for heart disease." "You probably have a vitamin deficiency."
"Let's discuss your risk factors for heart disease." Waist circumference is an indicator of central body fat. In men, a waist circumference greater than 40 inches (102 cm) is strongly associated with an increased risk for heart disease. High waist circumference alone cannot provide enough information about vitamin deficiency. Other signs and symptoms must be present and further assessment is warranted prior to making this statement. Protein deficiency is associated with abdominal distension and ascites, not high waist circumference. Because waist circumference is a measure of central body fat, it stays consistent over the course of the day. Chapter 13: Assessing Nutritional Status - Page 234
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? "When you pick up your prescription at the pharmacy, it would be a good idea to buy some over-the-counter iron supplements as well." "Let me know if you feel nauseous after you start these pills, because it's not uncommon." "This will make you urinate more often, so make sure you drink plenty of fluids." This might make you constipated at first, so try to include more fiber in your diet.
"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. Chapter 13: Assessing Nutritional Status - Page 229
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?" "Why don't you eat more meat? You need protein." "When did you first notice that you had this sore on your heel?" "What kinds of foods did you prepare when your husband was alive?"
"What prescribed and over-the-counter medicines do you take?" Explanation: When collecting dietary data for an older adult, it is important to gather information about prescribed and over-the-counter medications to assess for food-drug interactions and adverse effects of medications. Reference: Chapter 13: Assessing Nutritional Status - Page 219
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." "You could be making healthier food choices." "You should be exercising for longer periods of time." "You are retaining fluid."
"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. Chapter 13: Assessing Nutritional Status - Page 223
To calculate the ideal body weight for a woman, the nurse allows 6 pounds for each additional inch over 5 feet. 100 pounds for 5 feet of height. 80 pounds for 5 feet of height. 106 pounds for 5 feet of height.
100 pounds for 5 feet of height. Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 233
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? 130 lb 145 lb 135 lb 140 lb
145 lb Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 233
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? 18 20 22 16
16 Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 224
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? 20 BMI 22 BMI 19 BMI 21 BMI
19 BMI
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 20 BMI 22 BMI 21 BMI
19 BMI Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 234
At what percent of weight over ideal weight is a person considered obese? 40% 60% 100% 20%
20% Explanation: Obesity is defined as body weight 20% or more above ideal weight. Reference: Chapter 13: Assessing Nutritional Status - Page 222
A nurse is working with a client whose ideal body weight is 172 lb. At what weight would this client first be considered obese? 223.6 lb 240.8 lb 206.4 lb 189.2 lb
206.4 lb Explanation: Generally, a person who is 10% over ideal body weight (IBW) is considered overweight, whereas one who is 20% over IBW is considered obese. Twenty percent of 172 would be 34.4; 34.4 + 172 = 206.4. Reference: Chapter 13: Assessing Nutritional Status - Page 224
Which of the following is the BMI that indicates the lowest risk of developing health problems? 33 18 28 23
23 Explanation: A BMI in the normal range (18.5;24.9) carries the lowest risk of developing health problems. Being either underweight or overweight increases a person's risk of developing health problems. Reference: Chapter 13: Assessing Nutritional Status - Page 233
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? 18.9 34.4 24.4 29.9
24.4
An individual is considered obese when his or her BMI is: Less than 24 30-39 25-29 Greater than 40
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. Chapter 13: Assessing Nutritional Status - Page 224
A waist circumference of greater that which of the following is indicative of excess abdominal fat in men? 40 25 35 30
40 Explanation: A waist circumference greater than 40 inches for men or 35 inches for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation. Reference: Chapter 13: Assessing Nutritional Status - Page 234
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 34 52 29
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? 1 3 5 7
5 Explanation: When calculating ideal body weight for women, add 5 pounds for each additional inch over 5 feet. The other numerical values are incorrect. Reference: Chapter 13: Assessing Nutritional Status - Page 233
A client describes probable night blindness. Intake of what vitamin should be evaluated? D C B A
A
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 27-year-old woman with pneumonia A 33-year-old athlete on steroids A 39-year-old who has been in remission from cancer for 4 years A 42-year-old client with irritable bowel syndrome
A 33-year-old athlete on steroids A client taking steroids may gain weight. Chapter 13: Assessing Nutritional Status - Page 222
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 45-year-old man who regularly works 8-hour days A 33-year-old smoker who says that food has lost its taste A teenaged girl who typically snacks on carrots and apple slices A single mother of three who makes $20,000 per year A 12-year-old girl with Crohn's disease An elderly woman with Alzheimer's disease
A single mother of three who makes $20,000 per year A 33-year-old smoker who says that food has lost its taste An elderly woman with Alzheimer's disease A 12-year-old girl with Crohn's disease Explanation: Risk factors for malnutrition include the following: lower socioeconomic status, making nutritious foods unaffordable; dental and other factors such as difficulty chewing, loss of taste sensation, and depression; disorders whereby food is self-limited or refused, such as in dementia (Alzheimer disease); and chronic diseases that may interfere with absorption or use of nutrients, such as Crohn disease, cirrhosis, or cancer. Carrots and apple slices are a healthy snack. Working 8-hour days is normal and would not increase risk for malnutrition. Reference: Chapter 13: Assessing Nutritional Status - Page 221-222
The nurse conducting a nutritional assessment should notify the healthcare provider of a possible eating disorder based on which finding? Increased albumin level Absence of menstrual periods Increased upper arm muscle mass Increased subcutaneous fat in abdomen
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. Chapter 13: Assessing Nutritional Status - Page 227
The nurse conducting a nutritional assessment should notify the healthcare provider of a possible eating disorder based on which finding? Increased subcutaneous fat in abdomen Increased upper arm muscle mass Absence of menstrual periods Increased albumin level
Absence of menstrual periods Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 227
A patient who adheres to the dietary laws of Judaism is in traction and confined to bed. The patient needs assistance with the evening meal of chicken, rice, beans, a roll, and a carton of milk. Which nursing approach is most representative of promoting wellness? Ask a family member to assist the patient with the tray and the overbed table, then straighten the area in an attempt to provide a pleasant atmosphere for eating. Ask whether the patient would like to make any substitutions in the foods and fluids received. Remove items from the overbed table to make room for the dinner tray. Push the overbed table toward the bed so that it will be within the patient's reach when the dinner tray arrive
Ask whether the patient would like to make any substitutions in the foods and fluids received. Explanation: Wellness involves being proactive and being involved in self-care activities aimed toward a state of physical, psychological, and spiritual well-being. With this in mind, health care providers must aim to promote positive changes that are directed toward health and well-being. The sense of wellness has a subjective aspect that addresses the importance of recognizing and responding to patient individuality and diversity in health care and nursing. Although all of the actions listed would promote the patient's comfort, addressing the patient's religious dietary needs is most representative of promoting wellness. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 1: Health Care Delivery and Evidence-Based Nursing Practice, p. 6.
You are assigned five patients on your nursing unit. Which patient is. most risk for pressure ulcers? A) A 72 year old female weighing 82 lbs with stress incontinence and dementia. B) A 90 year old with congestive heart failure who has 3+ pitting edema lower extremities. C) A 6 month old with the flu. D) An ambulatory 88 year old with dementia who is admitted with shingles.
B) A 90 year old with congestive heart failure who has 3+ pitting edema lower extremities.
A nursing student is caring for a male client who has been admitted in a severely malnourished state. For what signs of malnutrition would the student observe? Cranium that appears larger in proportion to body Liver pain Increased scrotum size Bleeding of the gums
Bleeding of the gums Explanation: Clinical findings of malnutrition can occur in many places throughout the body. Visible signs include muscle wasting, particularly in the temporal area, and muscle weakness; tongue atrophy; and bleeding or changes in the integrity or hydration status of the skin, hair, teeth, and gums. Reference: Chapter 13: Assessing Nutritional Status - Page 304089
Waist circumference guidelines may not be accurate for adult clients who are shorter than 152.4 cm (5 ft) in height. This restriction is also a concern for which other anthropometric measurement? Ideal weight. Triceps skinfold measurements. Body mass index (BMI). Mid-arm circumference.
Body mass index (BMI). As with BMI, waist circumference guidelines may not be as accurate with adult clients who are shorter than five feet in height.
Of the following measurements, which one helps to determine if a client is underweight, normal weight, or obese? Waist-hip ratio. Body mass index. Triceps skinfold. Mid-arm circumference.
Body mass index. Explanation: BMI18.5 is considered underweight. BMI between 25.0 and 29.9 is considered overweight and increases risk for health problems. A BMI of 30 or greater is considered obese and places the client at a much higher risk for type 2 diabetes, cardiovascular disease, osteoarthritis, and sleep apnea. Reference: Chapter 13: Assessing Nutritional Status - Page 233
The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? A) Eschar B) Slough C) Granulation D) Purulent drainage
C) Granulation
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? Cardiovascular disease Osteoporosis Cancer Diabetes
Cancer Explanation: A population that is particularly at risk for developing malnutrition is the client with cancer. Wasting syndrome, known as cachexia or cancerous or malignant cachexia, can develop. This type of malnutrition is characterized by an abnormal metabolic rate, anorexia, muscle wasting, severe weight loss, and general decline in condition. Cachexia is not associated with cardiovascular disease, diabetes, or osteoporosis. Reference: Chapter 13: Assessing Nutritional Status - Page 222
The nurse should perform which priority assessment on a client with a history of a high hydrogenated fat intake? Respiratory Musculoskeletal Cardiac Skin
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). Chapter 13: Assessing Nutritional Status - Page 232
21s The nurse should perform which priority assessment on a client with a history of a high hydrogenated fat intake?
Cardiac Explanation: 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). Chapter 13: Assessing Nutritional Status - Page 232
A nurse is assessing the hydration status of a young client with a high temperature. Which interventions should the nurse implement in this case? Select all that apply. Check skin turgor Observe skin moisture Assess the nails Palpate radial pulse Inspect tongue condition
Check skin turgor Observe skin moisture Inspect tongue condition Palpate radial pulse Explanation: Checking the clients skin turgor is pinching a small fold of skin, observing elasticity, and watching how quickly the skin returns to the original position. Tenting (skin does not return to original position) can indicate dehydration. Observing skin moisture helps to find abnormal and normal findings. Skin that is not excessively dry indicates a normal finding, and dry and flaky skin indicates an abnormal finding. When inspecting the tongue and furrows, the abnormal findings are dry tongue with visible papillae and several longitudinal furrows. A weak or thready pulse may indicate dehydration in a client with a high temperature. Inspecting a clients nails is done when assessing for vitamin deficiency and not when conducting hydration assessment. Abnormal nails indicate protein deficiency and are not pertinent to a hydration assessment. Reference: Chapter 13: Assessing Nutritional Status - Page 230
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? Unsaturated fat Protein Saturated fat Cholesterol
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. Chapter 13: Assessing Nutritional Status - Page 218
It is a religious holy day. The hospitalized client is withdrawn, occasionally tearful, and requests a minister to see him. Family is at the bedside. What action would the nurse take to address the client's spiritual distress on this day? Provide religious material for the client to read. Contact the chaplain to request to see the client today. Ask the client, "Can we pray together?" Encourage the family to talk to the client.
Contact the chaplain to request to see the client today. Explanation: The client has asked for a minister to see him. To best address the client's need, the nurse would refer to the chaplain. Even on a holy day, there is usually a spiritual caregiver on call for the hospital. Encouraging the family to talk to the client ignores the client's request. The other options may bring some relief to the client, but they still ignore his request for a spiritual caregiver. Reference: Chapter 46: Spirituality - Page 1807
Which of the following clients will have an increased metabolic rate and require nutritional interventions? An older, sedentary adult with painful joints. A person with a serious infection and fever. A healthy young adult who works in an office. A retired person living in a temperate climate.
DA person with a serious infection and fever. Explanation: Factors that increase metabolic rate include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of some hormones. Aging, prolonged fasting, and sleep decrease metabolic rate. Reference: Chapter 13: Assessing Nutritional Status - Page 222
A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply. Sleep apnea Anorexia Diabetes Cirrhosis Hypertension
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. Chapter 13: Assessing Nutritional Status - Page 233
A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants? Provide the infant with soft toys or a feeding bottle. Ask a child specialist to be present during treatment. Encourage parents to be present during the treatment. Tell the infant that it will be over within a minute.
Encourage parents to be present during the treatment. Explanation: When caring for infants and newborns, the best nursing intervention is to encourage the parents to be present during the medical treatment. There is no need for the nurse to ask for a child specialist to be present during the treatment. Instead, the nurse should involve the parents in the caring process as the infant will feel more secure and comfortable in the presence of the parents. Providing the infant with toys, a feeding bottle, or trying to explain that it will be over soon will not pacify the child. Remediation:
In which disease process should a nurse expect to see a client with the presence of pitting edema? Liver disease Diabetes mellitus End stage renal disease Colon cancer
End stage renal disease Explanation: Pitting edema is a sign of fluid retention ; is commonly seen in client with cardiac or renal disease because the circulatory system cannot handle the excess fluid; it leaks into the tissues. Pitting edema is most commonly seen in the lower extremities. Colon cancer, diabetes mellitus, and liver disease do not normally cause pitting edema because these disease processes do not involve fluid retention. Reference: Chapter 13: Assessing Nutritional Status - Page 239
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 Underweight Obese Normal weight
Extreme 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. Chapter 13: Assessing Nutritional Status - Page 224
Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease? Clients with a BMI of 20. Females with 88.9 cm (35 in) or greater waist circumference. Males with 88.9 cm (35 in) or greater waist circumference. Clients with a BMI of 23.
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. Chapter 13: Assessing Nutritional Status - Page 233-234
Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease? Clients with a BMI of 20. Females with 88.9 cm (35 in) or greater waist circumference. Males with 88.9 cm (35 in) or greater waist circumference. Clients with a BMI of 23.
Females with 88.9 cm (35 in) or greater waist circumference. Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 233-234
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 Citrus fruits Red meat Dairy products
Green, leafy vegetables Explanation: Some medications or dietary supplements may decrease the client absorption of nutrients. Other medications&; therapeutic effects are affected by diet. For example, the therapeutic effects of warfarin (Coumadin) are lessened with the intake of large amounts of green, leafy vegetables. Red meat, dairy products, and citrus fruits are not known to interfere with warfarin. Reference: Chapter 13: Assessing Nutritional Status - Page 228
A nurse collects nutritional information on a client. Which statement by the client needs to be validated by careful objective data? "I eat small amounts of food 5 to 6 times a day." "Packing a lunch helps me to control my calorie intake." I drink two large bottles of caffeinated beverages every day. "I exercise about 30 minutes a day to control my weight."
I drink two large bottles of caffeinated beverages every day. Explanation: Excessive intake of diuretic fluids, such as coffee or other caffeinated beverages, can lead to dehydration. The nurse needs to validate how much a large bottle contains and collect objective data to assess for findings of dehydration. Packing a lunch to control calorie intake and exercising 30 minutes a day is healthy. Eating small amounts of food more frequently is also a helpful way to control weight. Reference: Chapter 13: Assessing Nutritional Status - Page 229-230
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 Fluid volume, excessive Activity intolerance Knowledge deficit
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. Chapter 13: Assessing Nutritional Status - Page 240
When teaching a nutrition class, what would you recommend for adults older than the age of 50? Increase foods rich in vitamin B6 and saturated fats Increase foods rich in vitamin E and folic acid Increase foods rich in vitamin B6 and vitamin D Increase foods rich in vitamin B12 and calcium
Increase foods rich in vitamin B12 and calcium Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 290530
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? Provide support or hold the client to record the height Obtain this information subjectively from the client Use a standard chart for height by age and gender Measure the arm span to estimate 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. Chapter 13: Assessing Nutritional Status - Page 232
The nurse is caring for a client recovering from surgery with an open wound. The nurse should encourage this client to increase the intake of which foods? Leafy green vegetables and fruit. Meat and dairy products. Citrus fruits and mixed vegetables. Whole grains and nut butter.
Meat and dairy products. Explanation: The nurse should place emphasis on protein sources, such as milk and meat, to boost tissue building for this client. Reference: Chapter 13: Assessing Nutritional Status - Page 218
You are the clinic nurse assessing a new client that has come in to see a physician. The assessment data that you collect reveals that the client is a 23 year-old female weighing 175 lb with a height of 5 ft 3 in. Her body mass index is 31. What would she be considered? Obese Overweight Underweight Average weight
Obese Explanation: A body mass index of 31 is considered clinically obese. People who have a BMI lower than 18.5 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Those who have a BMI of 25 to 29 are considered overweight; those with a BMI of 30 to 39, obese; and those with a BMI greater than 40, extremely obese. Reference: Chapter 13: Assessing Nutritional Status - Page 224
What can cause edema in a client with a weak heart? Hyperproteinemia Hyponatremia Overhydration Dehydration
Overhydration Explanation: Edema may be secondary to a protein deficiency or overhydration in a client with a weak heart. Reference: Chapter 13: Assessing Nutritional Status - Page 222
A nurse is of the Catholic faith and votes pro-life. This nurse is considered to have: personal values. moral agency. legal obligations. ethics.
Personal values. Explanation: The only information given here tells us that this nurse has personal values on a particular issues. Personal values are ideas or beliefs a person considers important and feels strongly about. Moral agency is the ability to do the ethically right thing because one knows it is the right thing to do. Ethics is a systematic study of principles of right and wrong conduct, virtue and vice, and good and evil as they relate to conduct and human flourishing. Legal obligations are behaviors and actions required by law. Reference: Chapter 6: Values, Ethics, and Advocacy - Page 98
What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors? Inform the client that the pen mark on the abdomen should not be washed off Ask the client to be seated and relaxed when taking the measurement Ensure that the client has had a full meal before measuring the abdomen Place the tape measure behind the client and measure at the umbilicus
Place the tape measure behind the client and measure at the umbilicus The nurse should place the tape measure behind the client and measure at the umbilicus. The umbilicus should be the starting point when measuring the abdomen, especially when distention is apparent. Abdominal measurement is generally taken in the morning after voiding, not after the client has had a full meal. The ideal position to measure the abdomen is standing, not sitting. The nurse informs the client that the pen mark on the abdomen should not be washed off only if the client is being monitored on a regular basis to determine progress of treatment for abdominal distention. Chapter 13: Assessing Nutritional Status - Page 234
An young adult female presents at the clinic with fatigue and long, heavy periods. Blood is drawn for laboratory testing, and findings include both low hemoglobin and hematocrit levels. What can these low levels indicate? Poor iron absorption High-folate level Decreased calcium level Fluid deficit
Poor iron absorption Explanation: Low hemoglobin and hematocrit counts may indicate poor iron intake or absorption. Other factors such as bleeding, fluid excess, or low intake of vitamin B12 and folate may also decrease these values. Reference: Chapter 13: Assessing Nutritional Status - Page 241
Malnutrition can be too much or too little nutrition. What can malnutrition do in the human body? Decreased risk of disease complications Decrease wound healing time Contribute to shorter hospital stays Prolong confinement to bed
Prolong confinement to bed Explanation: Malnutrition interferes with wound healing, increases susceptibility to infection, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of clients to bed. Therefore options A, B and C are incorrect. Reference: Chapter 13: Assessing Nutritional Status - Page 221
The nurse is caring for a patient with Parkinson disease. The patient informs the nurse that the patient has been angry with God because of the worsening illness, but after talking to the hospital chaplain, the patient is ready to return to the church choir and become active again in the group at the church. What is an appropriate nursing diagnosis for this patient? Risk for Loneliness Impaired Religiosity Readiness for Enhanced Spiritual Well-Being Spiritual Distress
Readiness for Enhanced Spiritual Well-Being Explanation: The most appropriate diagnosis for this patient is Readiness for Enhanced Spiritual Well-Being. The patient desires to experience and integrate meaning and purpose in life through connection with self, others, art, music, literature, nature, or a power greater than themself.
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? Structure eating so that no more than 500 calories are consumed each day. Reducing her weight by 5% can lower her risk Reduce daily calorie intake by 100 calories each day. Plan to reduce weight by 20% in 6 months.
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. Chapter 13: Assessing Nutritional Status - Page 234
A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking? Body mass index Mid-arm circumference Waist circumference Skinfold thickness
Skinfold thickness Skinfold calipers are used to measure triceps skinfold thickness to evaluate the degree of subcutaneous fat stores. Body mass index is calculated by first measuring height and weight by means of a balance beam scale with height attachment and then entering these values into a formula. A tape measure is used to measure waist and mid-arm circumferences. Chapter 13: Assessing Nutritional Status - Page 237
A client has just given birth to a stillborn infant. The client is sobbing and says God is punishing the client for some bad choices in the past. The client reports having always believed in God as a loving and caring presence in life but now feeling that the client's faith is destroyed. Which nursing diagnoses would be appropriate for the nurse to include in this client's care plan? Select all that apply. Impaired Parenting Spiritual Distress Defensive Coping Grieving Risk for Suicide
Spiritual Distress Grieving Explanation: The client feels the stillbirth of the child was caused by a vindictive God and is therefore considering leaving the client's religious faith. The client is grieving the loss of the child. There is no evidence of impaired parenting, risk for suicide, or defensive coping. Reference: Chapter 16: Outcome Identification and Planning - Page 395-396
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? Lentils Fortified breads Sunshine Orange juice
Sunshine Explanation: 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. Chapter 13: Assessing Nutritional Status - Page 232
A nurse convinces a client who is a Jehovah's Witness that receiving blood products is more important than the legalistic components of religion. What client reaction may be expected following this mandated change? The client states, "I can't get over my feelings of legalism as a Jehovah's Witness." The client states, "Why isn't blood administration forced on all who need that treatment?" The client states, "I am glad that nurse told me what to do." The client states, "I feel like I abandoned my religion."
The client states, "I feel like I abandoned my religion." Explanation: When clients are forced to participate in care that conflicts with their values, feelings of guilt and abandonment are likely. These feelings may deepen and threaten the client's well-being. The other answer choices are not related to mandated change. Reference: Chapter 5: Cultural Diversity - Page 94
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 determine if the client is interested in preparing nutritious food To assess if the client has the ability to obtain or prepare food To determine the client's understanding of the principles of nutrition To evaluate the client's food preferences
To assess if the client has the ability to obtain or prepare food Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 221
When would a nurse obtain a mid-arm circumference measurement? To confirm an abnormal albumin level. To provide percentage of body fat and muscle tissue. To assist in determining body mass index. To screen for nutritional excess or deficits.
To provide percentage of body fat and muscle tissue. Explanation: Measure mid-arm circumference (MAC) evaluates skeletal muscle mass and fat stores. Reference: Chapter 13: Assessing Nutritional Status - Page 236
The nurse might expect the client admitted with dehydration to have tachycardia. False True
True Tachycardia, a weak pulse and decreased blood pressure can indicate dehydration, while a bounding pulse and increased blood pressure may mean overhydration. Chapter 13: Assessing Nutritional Status - Page 232
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? Increased intake of meats Variety Decreased intake of grains Weight loss
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. Chapter 13: Assessing Nutritional Status - Page 220
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? Iodine Vitamin B Niacin Thiamine
Vitamin B Explanation: The suggested implication for a red, beefy tongue is vitamin B deficiency. The finding of a red, beefy tongue in a client does not indicate thiamine deficiency, or iodine or niacin deficiency. Altered mental status is due to thiamine deficiency. A swollen neck is caused by iodine deficiency. Cracks in the corners of the mouth are because of niacin deficiency. Reference: Chapter 13: Assessing Nutritional Status - Page 232
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 Mid-arm circumference Triceps skinfold measurement Mid-arm muscle circumference
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. Chapter 13: Assessing Nutritional Status - Page 234
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." "You should transition to skim milk by giving him 2% milk first." "You should start seeing some weight loss while he's drinking the skim milk." "As he starts walking more, he will develop more fat rolls."
Whole milk is recommended until age 2." Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 218
It would be a priority for the nurse to provide counseling about nutrition and exercise for weight loss for which client? a client with a body mass index of 23 and high LDL cholesterol a client with body mass index of 27 and blood pressure of 145/80 mm Hg a client with body mass index of 18.5 and family history of heart disease a client with a body mass index of 25 and normal HDL cholesterol
a client with body mass index of 27 and blood pressure of 145/80 mm Hg Explanation: The client with a body mass index (BMI) of 27 is overweight and has hypertension. The nurse should offer strategies for weight loss to prevent the progression of cardiovascular disease. A client with a BMI of 18.5 borders on normal and underweight. Despite having a family history of heart disease, the client should be discouraged from further weight loss. Other risk factors for heart disease should be identified and treated as necessary. The client with a BMI of 23 is in the normal range; therefore, pursuing weight loss is not indicated. Further monitoring of the LDL cholesterol is warranted, however. The client with a BMI of 25 would be considered on the borderline of the overweight category; however, the HDL cholesterol is normal. Cardiovascular risk associated with the BMI is not higher in the absence of other risk factors. Reference: Chapter 13: Assessing Nutritional Status - Page 233
While conducting a physical examination, the nurse notices the client's mucous membranes are pale in color. Which nutritional deficiency is most likely for this client? vitamin C vitamin A protein anemia
anemia Explanation: Pale mucous membranes are common in anemia due to decreased blood flow and/or red blood cells in the body. Vitamin A deficiencies are most likely if the signs and symptoms include petechiae, ecchymoses, or poorly healing sores. A protein deficiency is most likely if there is the presence of edema, abdominal distension, or muscle wasting. A vitamin C deficiency is most likely if the client reports muscle and joint pain, bleeding gums, or poorly healing wounds. Reference: Chapter 13: Assessing Nutritional Status - Page 232
During an assessment the nurse suspects that a client has a vitamin C deficiency. What information did the nurse use to make this clinical determination? bone pain bleeding gums dry flaky skin paresthesias
bleeding gums Explanation: A manifestation of vitamin C deficiency are bleeding gums. Bone pain is associated with a vitamin D deficiency. Paresthesias are associated with vitamin B12, pyridoxine, or thiamine deficiency. Dry flaky skin is associated with a vitamin A, vitamin B-complex, or linoleic acid deficiency. Reference: Chapter 13: Assessing Nutritional Status - Page 232
A client has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply. temperature medications cholesterol activity level blood pressure
blood pressure cholesterol activity level Reference: Chapter 13: Assessing Nutritional Status - Page 238
The nurse educator is discussing spirituality for nurses in a mental health class. The nurse educator asks a student nurse, "Which of the following is most consistent with spirituality?" The student nurse identifies which description? participation in common ways of worshiping closely intertwined with beliefs about health and mental illness living according to one's beliefs feeling a connection to a higher power
feeling a connection to a higher power Explanation: Spirituality develops over time and is a dynamic, conscious process characterized by two movements of transcendence; either deep within the self or beyond the self. Self-transcendence involves self-reflection and living according to one's values in establishing meaning to events and a purpose to life. Closely intertwined with beliefs about health and mental illness, living according to one's beliefs, and participation in common ways of worshipping are not things that are most consistent with spirituality. Reference: Chapter 7: Client's Response to Illness - Page 119 - 120
The nurse is caring for an adult female client whose BMI is 38.7. The nurse should instruct the client that she is at greater risk for heart attack. osteoporosis. stomach cancer. rheumatoid arthritis.
heart attack. Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 233
The nurse works in an institution that expects nurses to initiate referrals to social or spiritual resources. What might trigger a nurse to initiate such a referral? Select all that apply. a client expressing a cultural concern impending death a client requesting occupational therapy a client requesting time alone family conferences
impending death family conferences a client expressing a cultural concern Explanation: Results that might trigger a consult include clients and families expressing social, cultural, or spiritual concerns; death; receiving a terminal diagnosis; comfort care; family conferences; and crisis. A client requesting time alone or occupational therapy would not usually trigger a social or spiritual referral.
Which factors should the nurse consider when counseling a client who is having difficulty gaining weight? Select all that apply. quality of sleep access to financial resources location of grocery stores in the client's area presence of food allergies mood dysregulation
location of grocery stores in the client's area access to financial resources presence of food allergies mood dysregulation Explanation: Limited access to food stores will determine if the client is able to obtain a variety of foods and in a sufficient quantity. Lack of finances will prevent the client from being able to obtain sufficient quantity of nutritionally dense foods. Mood problems such as depression can lead to low or no appetite. Food allergies can limit the types of foods the client is able to consume as well as possibly alter the absorption of nutrients in the gastrointestinal system. Although quality of sleep is a factor in overall health, it is not a factor directly linked to the client's ability to gain weight effectively. Reference: Chapter 13: Assessing Nutritional Status - Page 221
When evaluating data on a client with an eating disorder, the nurse would expect to find bradycardia hypertension magenta tongue yellow sclerae
magenta tongue Reference: Chapter 13: Assessing Nutritional Status - Page 232
Which culturally related perspective on illness/disease involves a belief in supernatural forces or a higher power? magico-religious naturalistic or holistic biomedical or scientific homeopathic
magico-religious Explanation: According to the magico-religious perspective, supernatural forces dominate. Examples include faith healing in some Christian faiths and voodoo or witchcraft in some Caribbean cultures. Health beliefs are a person's ideas about what causes illness, the role of the sick person, how to restore health, and how one stays healthy. The biomedical or scientific view is generally shared by Western healthcare personnel. An example is the belief that bacterial or viral organisms cause meningitis. The natural/holistic view espouses that human beings are only one part of nature. Natural balance or harmony is essential for health. Homeopathy is an alternative treatment modality. It is not a cultural view of illness/disease. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 7: Overview of Transcultural Nursing, p. 109. Chapter 7: Overview of Transcultural Nursing - Page 109
A college foreign exchange student is living with a family in England and is confused about the family's Catholic prayers and rituals. The student longs for her Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress? spiritual guilt spiritual alienation spiritual anger spiritual loss
spiritual alienation Explanation: Spiritual alienation occurs when an individual is separated from one's faith community. Spiritual guilt is the failure to live according to religious rules. Spiritual anger is the inability to accept illness. Spiritual loss occurs when one is not able to find comfort in religion.
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. who is 182.8 cm (6 ft) tall. with diabetes. with osteoarthritis.
who is a bodybuilder. Explanation: 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. Reference: Chapter 13: Assessing Nutritional Status - Page 231