Chapter 11: Nutritional Assessment

14. The nurse is performing a nutritional assessment on a 15-year-old girl, who tells the nurse that she is "so fat." Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurse's appropriate response would be: A. "How much do you think you should weigh?" B. "Don't worry about it; you're not that overweight." C. "The best thing for you would be to go on a diet." D. "I used to always think I was fat when I was your age."

ANS: A Adolescents' increased body awareness and self-consciousness may cause eating disorders such as anorexia nervosa or bulimia, conditions in which the real or perceived body image does not compare favorably to an ideal image. The nurse should not belittle the girl's feelings, provide unsolicited advice, or agree with the adolescent

12. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? A. Certain drugs can affect the metabolism of nutrients. B. The nurse needs to assess the patient for allergic reactions. C. Medications need to be documented on the record for the physician's review. D. Medications can affect one's memory and ability to identify food eaten in the last 24 hours.

ANS: A Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct

11. The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status? A. The absorption of nutrients may be impaired. B. The constipation may represent a food allergy. C. She may need emergency surgery for the problem. D. The gastrointestinal problem will increase her caloric demand.

ANS: A Gastrointestinal symptoms such as vomiting, diarrhea, or constipation may interfere with nutrient intake or absorption. The other responses are not correct

28. After completing a diet assessment on a 30-year-old woman, the nurse suspects that she may be deficient in iron. Laboratory studies to obtain to verify this condition would be: A. Hemoglobin and hematocrit. B. Cholesterol and triglycerides. C. Urinalysis. D. Serum albumin

ANS: A The hemoglobin determination is used to detect iron-deficiency anemia. Hematocrit, a measure of cell volume, is also an indicator of iron status. Cholesterol and triglyceride levels test for hyperlipidemia; serum albumin measures visceral protein status. Urinalysis is a measure of renal function and does not reflect iron-deficiency anemia

17. When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: A. Height and weight. B. Leg circumference. C. Biceps skinfold thickness. D. Hip and waist measurement.

ANS: A The most commonly used anthropometric measures are height, weight, triceps skinfold thickness, elbow breadth, and arm and head circumferences.

41. During an assessment of a patient who has been homeless for several years, the nurse notices that this tongue is magenta in color. This is an indication of _____ deficiency. A. Iron B. Riboflavin C. Vitamin D and calcium D. Vitamin C

ANS: B "Magenta tongue" is a sign of riboflavin deficiency. In contrast, a pale tongue is probably attributable to iron deficiency. Vitamin D and calcium deficiency causes osteomalacia in adults, and vitamin C deficiency causes scorbutic gums

5. A mother and her 13-year-old daughter express their concern related to the daughter's recent weight gain and increase in appetite. Which of these statements represents information the nurse should discuss with them? A. It is necessary to diet and exercise at this age. B. Snacks should be high in protein, iron, and calcium. C. Teenagers who have a weight problem should not be allowed to snack. D. A low-calorie diet is important to prevent the accumulation of fat.

ANS: B After a period of slow growth in late childhood, adolescence is characterized by rapid physical growth and endocrine and hormonal changes. Caloric and protein requirements increase to meet this demand. Because of bone growth and increasing muscle mass (and, in girls, the onset of menarche), calcium and iron requirements also increase.

7. During a nutritional assessment of a 22-year-old male refugee, the nurse must remember to: A. Obtain a 24-hour dietary recall. B. Clarify what is meant by the term "food." C. Provide him with a standard dietary handbook. D. Assume that his diet is consistent with other refugees from the same country

ANS: B Although one may assume that the term "food" is a universal concept, the person should clarify what is meant by the term. The other responses are not appropriate for this situation.

27. The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation? A. Changes in fat distribution will affect the waist-to-hip ratio. B. Height measurements may not be accurate because of changes in bone. C. Declining muscle mass will affect the triceps skinfold measure. D. Mid-arm circumference is difficult to obtain because of loss of skin elasticity

ANS: B Height measures may not be accurate in individuals confined to a bed or wheelchair or those over 60 years of age because of osteoporotic changes.

16. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors is most likely to affect the nutritional status of an elderly person? A. Increase in taste and smell B. Living alone on a fixed income C. Change in cardiovascular status D. Increase in gastrointestinal motility and absorption

ANS: B Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that affects an elderly person's nutritional status.

8. The nurse is reviewing a patient's nutritional assessment. Which statement is true concerning the nutritional assessment? A. It is only useful in patients who are overweight. B. It identifies patients who are at risk of malnutrition. C. This assessment can only be thoroughly done by a dietician. D. It provides the nurse with physical findings related to all the systems.

ANS: B The purposes of the nutritional assessment are to (1) identify individuals who are malnourished or are at risk for development of malnutrition, (2) provide data for designing a plan of care that will prevent or minimize the development of malnutrition, and (3) establish baseline data for evaluating the efficacy of nutritional care

13. A patient tells the nurse that his food just doesn't have any taste anymore. The nurse's best response would be: A. "That must be really frustrating." B. "When did you first notice this change?" C. "My food doesn't always have a lot of taste either." D. "Sometimes that happens but your taste will come back."

ANS: B With changes in appetite, taste, smell, or chewing or swallowing, the examiner asks about the type of change and when the change occurred. These problems interfere with adequate nutrient intake. The other responses are not correct.

26. The mother of an 8-year-old boy is concerned about the amount of weight her son has gained. To determine whether this is a problem, the nurse will measure: A. Arm span. B. Waist-to-hip ratio. C. Skinfold thickness. D. Mid-upper arm circumference

ANS: C Determination of skinfold thickness or body mass index may be useful in evaluating childhood and teenage overnutrition.

42. A 50-year-old patient has been brought to the emergency department after a housemate found that he could not get out of bed alone. He has lived in a group home for years, but for several months he has not participated in the activities and has stayed in his room. The nurse assesses for signs of undernutrition, and x-rays reveal that he has osteomalacia, which is a deficiency of: A. Iron. B. Riboflavin. C. Vitamin D and calcium. D. Vitamin C

ANS: C Osteomalacia results from vitamin D and calcium deficiency in adults. Iron deficiency would result in anemia, riboflavin deficiency would result in "magenta tongue," and vitamin C deficiency would result in scurvy.

29. A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic today to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests? A. The risks of undernutrition B. Methods to reduce stress in her life C. Information regarding a diet low in saturated fat D. The fact that this condition is hereditary and there is nothing she can do to change the levels

ANS: C The patient with elevated cholesterol and triglyceride levels should be taught about eating a healthy diet that limits the intake of foods high in saturated (or trans) fats. Reducing dietary fats is part of the treatment for this condition. The other responses are not pertinent to her condition

34. The nurse in a family practice clinic is reviewing the patients scheduled for appointments. Which of these statements is true regarding routine laboratory testing in the following individuals? A. In pregnancy, no laboratory testing is needed unless problems with the pregnancy are suspected. B. In the elderly, laboratory values regarding cholesterol and triglycerides are the most important because of the risk of disease. C. Routine laboratory testing is not necessary during adolescence, except in cases of illness. D. Laboratory tests for iron and lead levels should be assessed at 9 to 12 months.

ANS: D In infancy (and childhood), laboratory tests are performed only when undernutrition is suspected,or if the child has an illness. However, lead and iron levels should be tested at 9 to 12 months of age. During adolescence, laboratory evaluation of hemoglobin, hematocrit, and urinalysis are performed. Many laboratory values are monitored during pregnancy, and older adults should be monitored for signs of renal insufficiency and over- or underhydration.

3. The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group? A. It is important to maintain adequate fat and caloric intake. B. The recommended dietary allowances for an infant are the same as for an adolescent. C. At this age the baby's growth is minimal so caloric requirements are decreased. D. The baby should be placed on skim milk to decrease the risk of coronary artery disease when older.

ANS: A Because of rapid growth, especially of the brain, infants and children younger than 2 years should not drink skim or low-fat milk or be placed on low-fat diets—fat (calories and essential fatty acids) is required for proper growth and central nervous system development.

24. In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of: A. Height and weight. B. Frame size and weight. C. Waist and hip circumferences. D. Mid-upper arm circumference and arm span.

ANS: A Body mass index, calculated by using height and weight measurements, is a practical marker of optimal weight for height and an indicator of obesity. The other options are not correct.

32. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include: A. Slowed gastrointestinal motility. B. Hyperstimulation of the salivary glands. C. An increased sensitivity to spicy and aromatic foods. D. Decreased gastrointestinal absorption causing esophageal reflux

ANS: A Normal physiological changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.

18. If a 29-year-old woman weighs 156 pounds and the nurse determines her ideal body weight to be 120 pounds, how would the nurse classify the woman's weight? A. Obese B. Mildly overweight C. Suffering from malnutrition D. Within appropriate range of ideal weight

ANS: A Obesity, due to caloric excess, refers to weight more than 20% above ideal body weight. For this patient, 20% of her ideal body weight would be 24 pounds, and greater than 20% of her body weight would be over 144 pounds. Therefore having a weight of 156 pounds would be considered obese.

25. The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk? A. 29-year-old woman whose waist is 33 inches and whose hips are 36 inches B. 32-year-old man whose waist is 34 inches and whose hips are 36 inches C. 38-year-old man whose waist is 35 inches and whose hips are 38 inches D. 46-year-old woman whose waist is 30 inches and whose hips are 38 inches

ANS: A The waist-to-hip ratio assesses body fat distribution as an indicator of health risk. A waist-to-hip ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of android (upper body obesity) and increasing risk for obesity-related disease and early death. The 29-year-old woman has a waist-to-hip ratio of 0.92, which is greater than 0.8. The 32-year-old man has a waist-to-hipratio of 0.94; the 38-year-old man has a waist-to-hip ratio of 0.92; the 46-year-old woman has a waist-to-hip ratio of 0.78.

1. The nurse recognizes that which of these persons is at greatest risk for undernutrition? A. 5-month-old infant B. 50-year-old woman C. 20-year-old college student D. 30-year-old hospital administrator

ANS: A Vulnerable groups for undernutrition are infants, children, pregnant women, recent immigrants, persons with low incomes, hospitalized people, and aging adults.

44. The nurse is assessing the body weight as a percentage of ideal body weight on an adolescent patient who was admitted for suspected anorexia nervosa. The patient's usual weight was 125 pounds, but today she weighs 98 pounds. The nurse calculates the patient's ideal body weight, and reaches which conclusion? A. She is experiencing mild malnutrition. B. She is experiencing moderate malnutrition. C. She is experiencing severe malnutrition. D. Her current weight is still within expected parameters

ANS: B By dividing her current weight by her usual weight, then multiplying by 100, a percentage of 78.4% is obtained. This means that her current weight is 78.4% of her ideal body weight. A current weight of 80% to 90% of ideal weight suggests mild malnutrition; a current weight of 70% to 80% of ideal weight suggests moderate malnutrition; a current weight of less than 70% of ideal weight suggests severe malnutrition.

30. In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find? A. An increase in hair growth B. Inadequate nutrient food intake C. Weight 10% to 20% over ideal D. Sore, inflamed buccal cavity

ANS: B Dysphagia, or impaired swallowing, interferes with adequate nutrient intake

31. A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate calories and appears well nourished. In further assessing her, what would the nurse expect to find? A. Poor skin turgor B. Decreased serum albumin C. Increased lymphocyte count D. Triceps skinfold less than standard

ANS: B Kwashiorkor (protein malnutrition) is due to diets that may be high in calories but contain little or no protein (e.g., low-protein liquid diets, fad diets, and long-term use of dextrose-containing intravenous fluids). The serum albumin would be less than 3.5 g/dL.

45. The nurse is assessing an obese patient for signs of metabolic syndrome. This condition is diagnosed when three or more certain risk factors are present. Which of these assessment findings are risk factors for metabolic syndrome? Select all that apply. A. Fasting plasma glucose level less than 100 mg/dL B. Fasting plasma glucose level greater than or equal to 110 mg/dL C. Blood pressure reading of 140/90 mm Hg D. Blood pressure reading of 110/80 mm Hg E. Triglyceride level of 120 mg/dL

ANS: B, C Metabolic syndrome is diagnosed when three or more of the following risk factors are present: (1) fasting plasma glucose level greater than or equal to 100 mg/dL; (2) blood pressure greater than or equal to 130/85 mm Hg; (3) waist circumference greater than or equal to 40 inches for men and 35 inches for women; (4) high-density lipoprotein cholesterol less than 40 in men and less than 50 in women; and (5) triglyceride levels greater than or equal to 150 mg/dL (ATP III, 2001).

21. When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are evaluated, which is important for the nurse to remember? A. These measurements are no longer necessary for the elderly. B. Derived weight measures may be difficult to interpret because of wide ranges of normal. C. These measurements may not be accurate because of changes in skin and fat distribution. D. Measurements may be difficult to obtain if the patient is unable to flex his elbow to at least 90 degrees

ANS: C Accurate mid-upper arm circumference and triceps skinfold measurements are difficult to obtain and interpret in older adults because of sagging skin, changes in fat distribution, and declining muscle mass. Body mass index and waist-to-hip ratio are better indicators of obesity in the elderly.

40. A pregnant woman who is HIV positive is asking the nurse about breastfeeding her infant. Which of these statements is true? A. There is not enough information to know whether it would be safe for her to breastfeed. B. It is safe for women who are HIV positive to breastfeed. C. Women who are HIV positive should not breastfeed because HIV can be transmitted through breast milk. D. She can breastfeed as long as she uses pumped breast milk.

ANS: C Although relatively few contraindications to breastfeeding exist, women who are HIV positive should not breastfeed because HIV can be transmitted through breast milk

35. A 16-year-old girl is being seen at the clinic for gastrointestinal complaints and weight loss. The nurse determines that many of her complaints may be related to erratic eating patterns, eating predominantly fast foods, and high caffeine intake. In this situation, which is most appropriate when collecting current dietary intake information? A. Schedule a time for direct observation of the adolescent during meals. B. Ask the patient for a 24-hour diet recall and assume this is reflective of a typical day for her. C. Have the patient complete a food diary for 3 days, including 2 weekdays and 1 weekend day. D. Use the food frequency questionnaire to identify the amount of intake of specific foods

ANS: C Food diaries require the individual to write down everything consumed for a certain time period. Because of the erratic eating patterns of this individual, assessing dietary intake over a few days would produce more accurate information regarding eating patterns. Direct observation is best used with young children or older adults

6. The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find? A. Obesity B. Hypotension C. Osteomalacia D. Coronary artery disease

ANS: C General undernutrition, hypertension, diarrhea, lactose intolerance, osteomalacia (soft bones), scurvy, and dental caries are among the more common nutrition-related problems of new immigrants from developing countries.

33. Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman? A. Decrease the amount of carbohydrates to prevent lean muscle catabolism. B. Increase the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis. C. Decrease the number of calories she is eating because of the decrease in energy requirements from loss of lean body mass. D. Increase the number of calories she is eating because of the increased energy needs of the elderly.

ANS: C Important nutritional features of the older years are a decrease in energy requirements as a result of loss of lean body mass, the most metabolically active tissue, and an increase in fat mass.

38. A 65-year-old man is brought to the emergency department after he was found dazed and incoherent, alone in his apartment. He has an enlarged liver and is moderately dehydrated. When evaluating his serum albumin level, the nurse must keep in mind that: A. Serum albumin levels will increase as liver function decreases. B. Serum albumin levels are a sensitive measure of early protein malnutrition. C. Low serum albumin levels may be caused by reasons other than protein-calorie malnutrition. D The results of the serum albumin measurement along with the patient's hemoglobin level should be considered.

ANS: C Low serum albumin levels may be caused by reasons other than protein-calorie malnutrition, such as an altered hydration status and decreased liver function

39. Which of these conditions is due to an inadequate intake of both protein and calories? A. Obesity B. Bulimia C. Marasmus D. Kwashiorkor

ANS: C Marasmus, protein-calorie malnutrition, is due to an inadequate intake of protein and calories or prolonged starvation. Obesity is due to caloric excess; bulimia is an eating disorder. Kwashiorkor protein malnutrition.

22. The nurse is concerned about the skeletal protein reserves of a patient who has been hospitalized frequently for chronic lung disease. Which of these measurements would be necessary to include in the assessment? A. Body mass index B. Weight and height C. Mid-arm muscle area D. Ideal body weight and frame size

ANS: C Mid-arm muscle area is a good indicator of lean body mass and thus skeletal protein reserves. These reserves are important in growing children and are especially valuable in evaluating persons who may be malnourished because of chronic illness, multiple surgeries, or inadequate dietary intake. The equation for calculating mid arm muscle area includes mid-upper arm circumference and mid-upper arm muscle circumference

19. How should the nurse perform a triceps skinfold assessment? A. After pinching the skin and fat, apply the calipers vertically to the fat fold. B. Gently pinch the skin and fat on the front of the patient's arm and then apply calipers. C. After applying the calipers, wait 3 seconds before taking a reading. Repeat the procedure three times. D. Instruct the patient to stand with the back to the examiner and arms folded across the chest and pinch the skin on the forearm

ANS: C Release the lever of the calipers while holding the skinfold. Wait 3 seconds and then take a reading. Repeat three times and average the three skinfold measurements.

4. A pregnant woman is interested in breastfeeding her baby, and asks several questions about the topic. Which information is appropriate for the nurse to share with her? A. Breastfeeding is best when also supplemented with bottle feedings. B. Babies who are breastfed often require supplemental vitamins. C. Breastfeeding is recommended for infants for the first 2 years of life. D. Breast milk provides the nutrients necessary for growth as well as natural immunity

ANS: D Breastfeeding is recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development and natural immunity. The other statements are not correct

36. The nurse is preparing to measure fat and lean body mass and bone mineral density. Which tool is appropriate? A. Measuring tape B. Skinfold calipers C. Bioelectrical impedance analysis D. Dual-energy x-ray absorptiometry

ANS: D Dual-energy x-ray absorptiometry (DEXA) measures both bone mineral density and fat and lean body mass. Bioelectrical impedance analysis (BIA) measures fat and lean body mass but not bone mineral density. Measuring tape measures distance or length, and skinfold calipers are used to skin fold thickness.

23. The nurse is measuring a patient's frame size. Which of these statements best describes the correct technique for measuring frame size? A. With the patient standing, measure the distance from the top of the head to the back of the heel. B. With the patient in a sitting position, measure the distance from the condyle of the humerus to the clavicle. C. With the patient's right arm extended forward and the elbow extended, measure the distance from fingertips to the condyle of the humerus. D. With the right arm extended forward and the elbow bent, use the calipers to measure the distance between the condyles of the humerus.

ANS: D Instruct the person to extend the right arm forward, perpendicular to the body. Bend the elbow to a 90-degree angle with the palm of the hand turned laterally. Facing the person, place the caliperson the condyles of the humerus. Read the distance between the condyles.

20. To assess the muscle mass and fat stores on a 40-year-old woman, the nurse would use: A. Triceps skinfold. B. Mid-thigh muscle area. C. Percent ideal body weight. D. Mid-upper arm circumference.

ANS: D Mid-upper arm circumference estimates skeletal muscle mass and fat stores. Triceps skinfold provides an estimate of the body fat stores or the extent of obesity or undernutrition. The other responses are not used to assess measures of nutritional status.

2. When assessing a patient's nutritional status, the nurse recalls that the best definition of optimal nutritional status is: A. Nutrients in excess of daily body requirements. B. Sufficient nutrients to provide for the minimum body needs. C. Sufficient nutrients for daily body requirements but not for increased metabolic demands. D. Sufficient nutrients to provide for daily body requirements and for increased metabolic demands.

ANS: D Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands resulting from growth, pregnancy, or illness.

9. The nurse is seeing for the first time a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity? A. Calorie count of nutrients B. Anthropometric measures C. Complete physical examination D. Measurement of weight and weight history

ANS: D Parameters used for nutrition screening typically include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data. The other responses reflect a more in-depth assessment rather than a screening.

37. The nurse is reviewing laboratory studies on a patient who may have protein malnutrition. Which of these measurements is an early indicator of protein malnutrition? A. Serum albumin B. Serum creatinine C. Nitrogen balance D. Serum transferrin

ANS: D Serum transferrin, with a half-life of 8 to 10 days, may be a more sensitive indicator of visceral protein status than albumin. Serum albumin has a relatively long half-life of 17 to 20 days.

15. The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of these foods are recommended? A. Foods that the child will eat, no matter what they are B. Foods easy to hold such as hot dogs, nuts, and grapes C. Any foods as long as the rest of the family is eating them D. Finger foods and nutritious snacks that can't cause choking

ANS: D Use of small portions, finger foods, simple meals, and nutritious snacks help to improve dietary intake. Foods likely to be aspirated should be avoided (e.g., hot dogs, nuts, grapes, round candies, popcorn).

43. An elderly patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patient's gums are swollen, ulcerated, and bleeding in some areas. The nurse suspects that the patient has what condition? A. Rickets B. Vitamin A deficiency C. Linoleic acid deficiency D. Vitamin C deficiency

ANS: D Vitamin C deficiency causes swollen, ulcerated, bleeding gums, known as scorbutic gums. Rickets is a condition related to vitamin D and calcium deficiency in infants and children. Linoleic acid deficiency causes eczematous skin. Vitamin A deficiency causes Bitot's spots and visual problems.

10. A patient is asked to indicate on a form how many times he eats a specific food. This would describe which of these methods for obtaining dietary information? A. Food diary B. Calorie count C. 24-hour recall D. Food frequency questionnaire

ANS: D With this tool, information is collected on how many times per day, week, or month the individual eats particular foods, which provides an estimate of usual intake.