Nutrition
During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations? a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. b. This measurement indicates that the patient is underweight and will need to take measures to gain weight. c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery. d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.
ANS: A A BMI of 25 to 29.9 is in the overweight range. A BMI of <18.5 is in the underweight range. A BMI of 30 to 34.9 is obesity class I, a BMI of 35 to 39.9 is obesity class II, and a BMI of >40 is obesity class III (morbid obesity). A BMI of 19 to 24 is in the normal range.
During a physical examination, the nurse notes that the patient's skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves and numbness and tingling in extremities d. Fissures and inflammation of the mouth
ANS: A Hair loss (alopecia) and hair that is easily removed from the scalp (easy pluckability), like dry, flaking skin, is caused by essential fatty acid deficiency. Inflammation of the tongue (glossitis) and fissured tongue are manifestations of a niacin deficiency. Inflammation of peripheral nerves (neuropathy) and numbness and tingling in extremities (paresthesia) are manifestations of a thiamin deficiency. Fissures of the mouth (cheilosis) and inflammation of the mouth (stomatitis) are manifestations of a pyridoxine deficiency.
An African American is at an increased risk for which of the following? (Select all that apply.) a. Vitamin D deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome
ANS: A, D, E, F Type 1 diabetes and celiac disease are more common in Northern European heritage.
The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern? a. The patient's son uses a marked pillbox to set up the patient's medications weekly. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient tells the nurse that a close friend recently died.
ANS: B A 10-pound weight loss in 1 month could indicate cancer or may be an indication of further progression of memory loss. Depression is also another common cause of weight loss. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an older patient would have friends who have died.
The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient? a. Regular diet b. Low sodium diet c. Pureed diet d. Low sugar diet
ANS: B A low sodium diet will prevent water retention which could increase blood pressure. Patients with hypertension would not be on a regular diet due to sodium content. A pureed diet is indicated for stroke patients who may have impaired swallowing. A low sugar diet is indicated for patients with diabetes.
During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein
ANS: C Dry and scaly skin is a manifestation of essential fatty acid deficiency. Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae. Vitamin B deficiency is too large a category to consider. Specific categories of vitamin B deficiency have been identified, such as pyridoxine and thiamine. Protein deficiency causes decreased pigmentation and lackluster hair.
During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall
ANS: D A 24-hour recall is useful as a quick screening tool to assess dietary intake. A food diary provides detailed information, but it is not convenient and requires a follow-up visit. A calorie count requires several days to collect data and requires a trained dietician to analyze the results. A comprehensive diet history may provide more accurate reflection of nutrient intake, but it is time consuming to acquire and requires a trained/skilled dietary interviewer.
The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? a. "Your weight is within normal limits. Continue maintaining with current lifestyle choices." b. "You are a little overweight. Cut down on calories and increase your activity, and you should be fine." c. "You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery." d. "You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."
ANS: D This patient is at an increased risk for sarcopenia and should be instructed to increase activity that includes strength training to prevent muscle loss. Diet is not indicated. A BMI of 31 is considered obese; however, this patient does not qualify for surgical intervention until BMI reaches over 35.
The mother of a preadolescent client diagnosed with an eating disorder believes it must be genetic because the client is adopted and the client's mother is very weight and exercise conscious. The nurse realizes which of the following? A) The mother is obsessed with weight and exercise, and the child learned the behavior. B) The child must have inherited a genetic predisposition to an eating disorder. C) The child must have a neurotransmitter abnormality. D) The mother is setting a good example with eating and exercise.
Answer: A Explanation: A) Many families of clients with eating disorders are achievement and performance oriented, with high ambition for the success of all members. In these families, body shape is related to success, and priorities are established for physical appearance and fitness. A family's focus on professional achievement as well as on food, diet, exercise, and weight control may become obsessive. The mother states that she is weight and exercise conscious, which could be a reason as to why the child has an eating disorder. There is not enough information to determine whether the child does or does not have a genetic predisposition to an eating disorder or a neurotransmitter abnormality. The mother is not setting a good example by being overly focused on eating and exercise.
What outcomes can be anticipated when the appropriate steps for managing celiac disease have been implemented? Select all that apply. A) The client is free of abdominal discomfort including bloating, gas, indigestion, nausea, and vomiting. B) The client is able to maintain normal or routine bowel habits. C) The client has diarrhea fewer than 3 days weekly. D) The client is able to maintain adequate nutritional status.
Answer: A, B, D Explanation: A) When the client with celiac disease is placed on a gluten-free diet, treatment generally is successful, as long as the client avoids gluten totally. Symptoms such as diarrhea and abdominal discomfort should be eliminated and nutritional status should improve.
A client diagnosed with celiac disease who has frequent diarrhea may have associated problems of: Select all that apply. A) Skin integrity. B) Fluid and electrolyte imbalance. C) Hair loss. D) Lifestyle issues.
Answer: A, B, D Explanation: Clients with diarrhea may have perianal skin irritation. Diarrhea disturbs the fluid and electrolyte balance. There is no known connection between diarrhea and hair loss. Diarrhea can disrupt normal life activities.
Parents of a child diagnosed with celiac disease have requested guidance on how to implement a gluten-free diet. In addition to a list of foods to include and exclude, what should the nurse address in her discussion with them? Select all that apply. A) Obtaining a dietary prescription B) Exercise recommendations C) Educational information and training on how to read labels D) Phone numbers and links for informational resources and support groups
Answer: A, C, D Explanation: A) A prescription will enable them to deduct the cost of special ingredients and commercially prepared products as a medical expense. Exercise, while beneficial, is not part of celiac disease treatment. Client and family teaching includes how to identify gluten-containing commercial products by reading labels and lists of ingredients. It is helpful to provide referrals to local support groups as well as informational resources.
A 10-year-old boy, recently diagnosed with celiac disease, has diarrhea and is underweight, vitamin-deficient, and anemic. In addition to removing gluten from his diet, what other recommendations might be considered? Select all that apply. A) Fat restriction B) A high-carbohydrate diet C) Vitamin supplements D) High-calorie, high-protein diet
Answer: A, C, D Explanation: A) If nutritional deficiencies are severe, vitamin and mineral supplements may be indicated. A high-kilocalorie, high-protein, low-fat, gluten-free diet is advised. In celiac disease, gastrointestinal dysfunction may cause carbo
The nurse in the Emergency Department is assessing a client with bulimia nervosa. Which assessment finding(s) indicate that the client is dehydrated? Select all that apply. A) Dry mouth B) Hypertension C) Concentrated urine D) General weakness E) Poor skin turgor
Answer: A, C, D, E Explanation: A) Hypertension would not be a sign that the client is dehydrated. A client who is dehydrated may exhibit hypotension, dry mouth, poor skin turgor, lightheadedness or dizziness, general weakness, decreased urine production, and concentrated urine.
An elementary school nurse has become aware of an increasing number of students who have been diagnosed with celiac disease. She requests a meeting with the school administration and dietician in order to suggest: Select all that apply. A) Inclusion of an educational module to inform students about gluten-free diets and choices. B) School lunches emphasizing low calorie selections. C) A school based prevention program to eliminate celiac disease. D) Daily inclusion of labeled gluten-free choices in the school lunch program.
Answer: A, D Explanation: Nursing care for pediatric clients centers on teaching the necessity of a gluten-free diet. It is important to provide the prescribed high-calorie, high-protein, low-fat, and gluten-free diet. Celiac disease is not preventable and nursing interventions focus on prevention and management of diarrhea and malnutrition.
During a routine physical examination, a preadolescent tells the nurse, "I am too fat and I'm going to do whatever I can to look like the girls on the cover of fashion magazines." Which risk factor does the nurse realize the client is exhibiting? A) A desire for a long-term profession B) Societal influences on body weight for girls C) Unrealistic expectations D) Family influences on body weight
Answer: B Explanation: A) Risk factors for the development of eating disorders include female gender, age, and societal influences including media stereotypes. The client is a preadolescent female who wants to look like the girls on the covers of fashion magazines. The client may be demonstrating unrealistic behavior; however, the risk factors are the client's age, gender, and desire to look like those in fashion magazines. No information is given about the family's influences on the client's body weight. The client may or may not be expressing a desire for a long-term profession.
The nurse caring for a client with bulimia is aware that the physician may order a medication to lessen binging and purging behaviors. Which medication would the nurse anticipate the physician will order? A) Mood stabilizer B) Antidepressant C) Antipsychotic D) Anxiolytic
Answer: B Explanation: A) The antidepressant fluoxetine (Prozac) is the only medication approved by the U.S. Food and Drug Administration for treating bulimia. This and other antidepressants may help individuals for whom depression and anxiety are at the root of bulimic behavior. Fluoxetine appears to lessen binging and purging behaviors, reduce the likelihood of relapse, and improve attitudes toward eating.
A client admitted with an eating disorder tells the nurse, "No matter what I do, I continue to be fat." What is the appropriate nursing diagnosis for this client? A) Ineffective Coping B) Disturbed Body Image C) Impaired Tissue Integrity D) Deficient Knowledge
Answer: B Explanation: A) The nursing diagnosis to support this client's needs is Disturbed Body Image. There is not enough information to determine whether the client does or does not have ineffective coping or deficient knowledge. The nurse is unable to determine whether the client has impaired tissue integrity based upon the client's information.
Which assessment findings indicate that a client being treated for anorexia nervosa has succeeded in her recovery? Select all that apply. A) The client is observed wearing wrinkled clothes, listening to a portable music device, and staring out the window. B) The client states that her menstrual cycle is regular and she is learning to prepare meals. C) The client's vital signs are within normal limits. D) The client's current weight is 75% of normal after 2 years of treatment. E) The client is observed telling her mother that she will eat dinner if her mother buys her new jeans.
Answer: B, C Explanation: A) Evidence that the care provided to a client with anorexia nervosa has been successful includes a regular menstrual cycle, learning to prepare meals, and vital signs within normal limits. The client whose weight is 75% of normal would need additional treatment. The client who tells her mother that she will eat if she gets new jeans is demonstrating manipulative behavior and is evidence that treatment has not been successful. The client who is wearing wrinkled clothes and staring out the window is not demonstrating positive self-care behaviors and would benefit from additional intervention.
An adolescent client currently weighs 50% of expected body weight and tells the nurse, "I get upset and can't eat because my mother is constantly forcing food on me." Which treatments are indicated for this client? Select all that apply. A) Family therapy B) Hospitalization C) Behavior modification D) Medication to increase appetite E) Placement with a foster family
Answer: B, C Explanation: A) Indications for hospitalization are a loss of 25-30% of body weight. The client currently weighs 50% of expected body weight and could need hospitalization. Behavior modification techniques are used extensively in combination with counseling and other methods in care of the hospitalized anorexic client. The client may benefit from family therapy, but the low body weight must be addressed first. Moving the client to a foster family is an extreme measure and might not help the problem. Medication to increase appetite is not an approved method of treatment for a client with an eating disorder.
What will the nurse assess in a client diagnosed with bulimia? Select all that apply. A) Increased urine output B) Hoarseness C) Poor skin turgor D) Low body temperature E) Elevated blood pressure
Answer: B, C Explanation: A) Physical signs of bulimia nervosa include hoarseness and esophagitis, dental enamel erosion, enlarged parotid glands, abrasions or calluses on knuckles from inducing vomiting, amenorrhea in about 40% of cases, concentrated urine, decreased urine output, hypotension, elevated temperature, poor skin turgor, and weakness. Elevated blood pressure, low body temperature, and increased urine output are not typically found in a client with bulimia.
A visiting nurse sees an 85-year-old woman who lives alone and has limited financial resources. The client has a history of celiac disease. What are some likely nursing diagnoses for this client? Select all that apply. A) Risk for Constipation B) Risk for Nutrition, Imbalance: less than body requirements C) Risk for Fluid Volume Imbalance D) Risk for Diarrhea
Answer: B, C, D Explanation: A) Constipation is not a normal manifestation of celiac disease. Nutritional imbalance, including anemia and vitamin deficiencies, is possible. Celiac disease impairs absorption of fluid and electrolytes, leading to excess water in the stool. Local manifestations of celiac disease include abdominal bloating and cramps, diarrhea, and steatorrhea.
A client tells the nurse that the thought of eating makes her anxious and nervous, and she just avoids it altogether. What is the appropriate plan for this client? A) Instruction on the role of nutrition in normal menstruation B) Instruction on the importance of nutrition for vital signs and muscle tone C) Interventions to address anxiety and feelings of being in control D) Instruction on nutrition
Answer: C Explanation: A) The client is articulating feelings of anxiety and nervousness regarding eating. The nurse needs to include interventions to address the client's anxiety and feelings of being in control. Instruction on nutrition, normal menstruation, and bodily functions such as vital signs and muscle tone may or may not be appropriate for the client at this time.
A 73-year-old African-American man with a history of celiac disease presents with abdominal cramps, pain, and diarrhea. He reports that he does not use alcohol, but his favorite foods are steak, cheese, and ice cream. What condition should the nurse consider likely based on the client's risk factors? A) Acute pancreatitis B) Appendicitis C) Lactase deficiency D) Food poisoning
Answer: C Explanation: The most common risk factor for pancreatitis is alcohol abuse. Appendicitis usually involves loss of appetite and nausea and/or vomiting soon after abdominal pain begins. Lactose intolerance is more common in Native Americans, Asians, Hispanics, and African-Americans and in those with a history of celiac disease. Food poisoning generally causes some nausea and vomiting.
