Prep U Chapter 13 Assessing Nutritional Status
A nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present?
Chronic dieting
Cachexia is characterized by a highly catabolic state with accelerated muscle loss. What is the other component of cachexia?
Chronic inflammatory response
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
A home care nurse is teaching a client's daughter meal planning for her mother who is recovering from a hip replacement surgery. Which of the following meals indicates that the daughter understands the concept of a nutritionally complete choice based upon the Food Guide Pyramid?
Ham sandwich with tomato on rye bread with peaches and yogurt
When teaching a nutrition class, what would you recommend for adults older than the age of 50?
Increase foods rich in vitamin B12 and calcium
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?
Measure the arm span to estimate height
Which statement about weight should a nurse keep in mind when evaluating a client's nutritional status?
Muscle, bone, fat, and fluid can account for excessive weight
After assessing a new client, the nurse documents findings in the medical record. What is the best example of documenting normal findings?
Nails are strong
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
How can a nurse best assess a client's dietary habits?
Obtain a 24 hour dietary recall of all foods and fluids consumed
What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?
Place the tape measure behind the client and measure at the umbilicus
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?
Reducing her weight by 5% can lower her risk
A nurse is providing nutritional instruction at a health fair. She instructs passersby on the characteristics of a nutrient that is the body's first source of energy, sparing use of other nutrients for this purpose, that raises the blood glucose level, is found in fruit juices, and that can be converted quickly into energy. To which of the following nutrients is the nurse referring?
Simple carbohydrates
A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking?
Skinfold thickness
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?
Sunshine
When beginning a height measurement on a 14-year-old, the nurse should instruct the client to stand on the scale with heels together.
True
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?
Variety
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?
Vitamin B
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
It would be a priority for the nurse to provide counseling about nutrition and exercise for weight loss for which client?
a client with body mass index of 27 and blood pressure of 145/80 mm Hg
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.
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."
An individual is considered obese when his or her BMI is:
30-39
A waist circumference of greater that which of the following is indicative of excess abdominal fat in men?
40
In which disease process should a nurse expect to see a client with the presence of pitting edema?
End stage renal disease
You are completing a health assessment on a new client. You note that the client has dry, dull, brittle hair and dry, flaky skin with poor turgor. What might this indicate?
Poor nutritional status
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 assess if the client has the ability to obtain or prepare food
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?
"Let's discuss your risk factors for heart disease."
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?
"This will make you urinate more often, so make sure you drink plenty of fluids."
The triage nurse suspects malnutrition in an older adult with altered mental status who has been brought to the emergency department by family members. What visible signs might the nurse have noticed that would lead to the suspicion of malnutrition? Select all that apply.
-Atrophied tongue -Temporal muscle wasting -Generalized muscle weakness -Dry eyes
A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply.
-Diabetes -Hypertension -Sleep apnea
A school nurse is assisting with taking baseline measurements of students at a middle school who are participating in a summer fitness program. Which pieces of equipment should the nurse gather specifically for taking anthropometric measurements? Select all that apply.
-Metric measuring tape -Balance beam scale with height attachment -Skinfold calipers -Marking pencil
A nurse begins a comprehensive physical examination on a client and notes that the client has a large amount of adipose tissue around the waistline. The nurse recognizes that this client should be assessed for an increased risk of which diseases? Select all that apply.
-Type 2 diabetes mellitus -Stroke -Hypertension
To calculate the ideal body weight for a woman, the nurse allows
100 pounds for 5 feet of height.
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?
16
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
Which of the following is the BMI that indicates the lowest risk of developing health problems?
23
When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet?
5
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 33-year-old athlete on steroids
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?
Cholesterol
