PrepU ch.13 assessing nutritional status
The nurse is conducting a nutrition history with a young adult with signs and symptoms of an eating disorder. Which question exemplifies the most effective way for the nurse to ask about body image? a."What would you change about your body, if you could?" b."Do you gather around a table with other people for meals?" c."How much do you exercise in one week?" d."How many meals and snacks do you eat in one day?"
a. "What would you change about your body, if you could?" Explanation: As per the nutrition history, the nurse should ask if there is anything that the client would like to change about his or her body in order to identify disturbance of body image. The client should be asked if he or she gathers around a table with others for meals if the nurse is asking about family dietary patterns. The client should be asked how much he or she exercises in one week if the nurse is asking about exercise patterns. The client should be asked how many meals and snacks he or she eats in one day if the nurse is trying to determine a food pattern. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 227. Chapter 13: Assessing Nutritional Status - Page 227
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? a."Your metabolism is slowing down." b."You are retaining fluid." c."You could be making healthier food choices." d."You should be exercising for longer periods of time."
a. "Your metabolism is slowing down." Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 223. Chapter 13: Assessing Nutritional Status - Page 223
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? a.19 BMI b.20 BMI c.21 BMI d.22 BMI
a. 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: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 234. Chapter 13: Assessing Nutritional Status - Page 234
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? a.Cholesterol b.Saturated fat c.Unsaturated fat d.Protein
a. Cholesterol Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 218. Chapter 13: Assessing Nutritional Status - Page 218
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? a.Extremely obese b.Underweight c.Normal weight d.Obese
a. Extremely obese Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 224. Chapter 13: Assessing Nutritional Status - Page 224
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? a.Measure the arm span to estimate height b.Provide support or hold the client to record the height c.Obtain this information subjectively from the client d.Use a standard chart for height by age and gender
a. Measure the arm span to estimate height Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 232. Chapter 13: Assessing Nutritional Status - Page 232
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? a.Reducing her weight by 5% can lower her risk b.Structure eating so that no more than 500 calories are consumed each day. c.Plan to reduce weight by 20% in 6 months. d.Reduce daily calorie intake by 100 calories each day.
a. Reducing her weight by 5% can lower her risk Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 234. Chapter 13: Assessing Nutritional Status - Page 234
It would be a priority for the nurse to provide counseling about nutrition and exercise for weight loss for which client? a.a client with body mass index of 27 and blood pressure of 145/80 mm Hg b.a client with body mass index of 18.5 and family history of heart disease c.a client with a body mass index of 23 and high LDL cholesterol d.a client with a body mass index of 25 and normal HDL cholesterol
a. 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: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 233. Chapter 13: Assessing Nutritional Status - Page 233
When evaluating data on a client with an eating disorder, the nurse would expect to find... a.magenta tongue b.bradycardia c.hypertension d.yellow sclerae
a. magenta tongue Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 232. Chapter 13: Assessing Nutritional Status - Page 232
The nurse measures the height and body weight of a female client with high muscle mass. The client weighs 175 pounds (79.4 kg) and is 68 inches (173 cm) tall. In which of these categories does the client's body mass index (BMI) fit best? a.normal b.overweight c.underweight d.obese
a. normal Explanation: Although a BMI of 26.6 for a female client would normally be categorized as overweight, this client has higher muscle mass. This needs to be considered when providing recommendations for a healthy body weight. Given the factors involved, this client should be categorized with a normal BMI. The client would be best suited to the overweight category if muscle mass was deemed low. A BMI of less than 18.5 is best suited to the underweight category. A BMI of 30 or greater is considered obese. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 234. Chapter 13: Assessing Nutritional Status - Page 234
The nurse conducting a nutritional assessment should notify the healthcare provider of a possible eating disorder based on which finding? a.Increased upper arm muscle mass b.Absence of menstrual periods c.Increased albumin level d.Increased subcutaneous fat in abdomen
b. 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: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 227. Chapter 13: Assessing Nutritional Status - Page 227
Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease? a.Clients with a BMI of 23. b.Females with 88.9 cm (35 in) or greater waist circumference. c.Males with 88.9 cm (35 in) or greater waist circumference. d.Clients with a BMI of 20.
b. 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: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, pp. 233-234. Chapter 13: Assessing Nutritional Status - Page 233-234
A diagnostic finding which is unrelated to nutritional deficiency is... a.High 24 hours urine creatinine b.High serum albumin c.High lymphocyte count d.Low prealbumin level
b. High serum albumin Explanation: Low serum albumin and prealbumin levels are most often used as measures of protein deficiency in adults. A lower than normal 24-hour urine creatinine may indicate loss of lean body mass and protein malnutrition. The total lymphocyte count may be reduced in people who are acutely malnourished as a result of stress and low-caloric feeding. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 241. Chapter 13: Assessing Nutritional Status - Page 241
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? a.Fluid volume, excessive b.Imbalanced nutrition c.Activity intolerance d.Knowledge deficit
b. Imbalanced nutrition Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 240. Chapter 13: Assessing Nutritional Status - Page 240
After assessing a new client, the nurse documents findings in the medical record. What is the best example of documenting normal findings? a.Clothing appears too large b.Nails are strong c.Hair is thin and appears oily d.Oral mucosa is pink with white patches
b. Nails are strong Explanation: Nails are strong; is the documentation that represents a normal finding. Clothing that is too large might indicate weight loss. Thin, oily hair is not generally a normal finding, nor are white patches on the oral mucosa. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 240. Chapter 13: Assessing Nutritional Status - Page 240
How can a nurse best assess a client's dietary habits? a.Assess for the presence of any chronic disease processes b.Obtain a 24 hour dietary recall of all foods and fluids consumed c.Obtain a height and weight and calculate a body mass index (BMI) d.Ask about how much food is eaten at an average meal
b. Obtain a 24 hour dietary recall of all foods and fluids consumed Explanation: The nurse can best assess dietary habits by asking the client about an average daily intake of food and fluids, where and when food is consumed, and if there are any conditions or diseases that may affect intake or absorption of nutrients. A height and weight may not accurately reflect dietary intake. One meal will not provide the best assessment of overall dietary habits. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 227. Chapter 13: Assessing Nutritional Status - Page 227
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? a.Complex carbohydrates b.Simple carbohydrates c.Proteins d.Fats
b. Simple carbohydrates Explanation: Briefly, carbohydrates are referred to as either simple or complex, depending on their chemical structure. Simple carbohydrates, such as found in fruit juice, are sugar with a simple structure that raises the blood glucose level and can be converted quickly into energy. Complex carbohydrates, such as whole grains, are starches that more slowly convert into energy and can also be used as an energy source. Carbohydrates are known as protein sparing because the body uses them for an energy source rather than breaking down proteins to fuel the body's energy needs. Protein and fat can be used as energy sources but are not the body's first source of energy, and are metabolized more slowly. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 217. Chapter 13: Assessing Nutritional Status - Page 217
To calculate the ideal body weight for a woman, the nurse allows... a.106 pounds for 5 feet of height. b.6 pounds for each additional inch over 5 feet. c.100 pounds for 5 feet of height. d.80 pounds for 5 feet of height.
c. 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: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 233. Chapter 13: Assessing Nutritional Status - Page 233
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? a.29 b.34 c.46 d.52
c. 46 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 approximately 46 for a client who is 6 feet 1 inch (73 inches) tall and 350 pounds. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 224. Chapter 13: Assessing Nutritional Status - Page 224
A client suffering from decreased muscle strength has been diagnosed with a low vitamin D level. The nurse should recommend that the client increase which vitamin source? a.Intake of liver b.Intake of beans and peas c.Exposure to sunshine d.Intake of dark green, leafy vegetables
c. Exposure to sunshine Explanation: Vitamin D can be obtained through exposure to sunlight. Food sources of vitamin D include fortified milk, orange juice, and cereals; certain fish; egg yolk; and mushrooms. Some people who are not exposed to enough sun and who don't get enough vitamin D through their diets may require dietary supplements. Liver, dried and cooked beans and peas, and dark green, leafy vegetables are all sources of folate, among other vitamins. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 232. Chapter 13: Assessing Nutritional Status - Page 232
When teaching a nutrition class, what would you recommend for adults older than the age of 50? a.Increase foods rich in vitamin B6 and saturated fats b.Increase foods rich in vitamin E and folic acid c.Increase foods rich in vitamin B12 and calcium d.Increase foods rich in vitamin B6 and vitamin D
c. 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: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 290530. Chapter 13: Assessing Nutritional Status - Page 290530
A client with a body mass index of 14 refuses to eat breakfast and cuts up the food for lunch and dinner but does not eat anything. What should the nurse suspect this client is demonstrating? a.cachexia b.bulimia nervosa c.anorexia nervosa d.metabolic syndrome
c. anorexia nervosa Explanation: The client's BMI is 14 which indicates underweight. Since the client refuses to eat breakfast and only cuts up food but does not eat lunch or dinner, these behaviors are consistent with anorexia nervosa. Cachexia is a highly catabolic state with accelerated muscle loss and a chronic inflammatory response. Bulimia nervosa is characterized by repeated binge eating followed by self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise. Metabolic syndrome is a group of findings that are used to determine a client's risk for developing diabetes mellitus. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 221. Chapter 13: Assessing Nutritional Status - Page 221
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? a.130 lb b.135 lb c.140 lb d.145 lb
d. 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: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 233. Chapter 13: Assessing Nutritional Status - Page 233
A nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present? a.Single parenthood b.Diabetes mellitus c.Excessive exercise d.Chronic dieting
d. Chronic dieting Explanation: Chronic dieting, especially with fad diets, can predispose an individual to malnutrition because the amount of needed nutrients is often lacking in an effort to lose weight quickly. Single parenthood is not a risk factor for malnutrition unless the parent is unable to gain access to shopping or suffers form a lower socioeconomic status. Diabetes mellitus is a chronic disease, not a lifestyle behavior. Excessive exercising may lead to weight loss but not malnutrition. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 221. Chapter 13: Assessing Nutritional Status - Page 221
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? a.Cheeseburger, carrot sticks and mushroom soup with crackers b.Spaghetti and meat sauce with a salad c.Chick and pepper stir fry and basmati rice d.Ham sandwich with tomato on rye bread with peaches and yogurt
d. Ham sandwich with tomato on rye bread with peaches and yogurt Explanation: The menu has a choice from each of the food groups from the Food Guide Pyramid. The other selections are incomplete choices. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 221. Chapter 13: Assessing Nutritional Status - Page 221
A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking? a.Body mass index b.Waist circumference c.Mid-arm circumference d.Skinfold thickness
d. Skinfold thickness Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 237. Chapter 13: Assessing Nutritional Status - Page 237
What is the most common measurement used to determine abdominal visceral fat? a.Waist circumference. b.Body mass index. c.Subcutaneous fat determination. d.Triceps skinfold thickness.
a. Waist circumference. Explanation: Waist circumference is the most common measurement used to determine the extent of abdominal visceral fat in relation to body fat. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 234. Chapter 13: Assessing Nutritional Status - Page 234
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? a.18.9 b.24.4 c.29.9 d.34.4
b. 24.4 Explanation: Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 234. Chapter 13: Assessing Nutritional Status - Page 234
What assessment parameters are included when assessing a client's nutritional status? (Mark all that apply.) -Ethnic mores -Body mass index -Clinical examination findings -Wrist circumference -Dietary data
-Body mass index -Clinical examination findings -Dietary data Explanation: The sequence of assessment of parameters may vary, but evaluation of nutritional status includes one or more of the following methods: measurement of body mass index and waist circumference, biochemical measurements, clinical examination findings, and dietary data. Ethnic mores and wrist circumference are not assessment parameters for nutritional status. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 227. Chapter 13: Assessing Nutritional Status - Page 227
Which of the following are causes of weight loss? (Mark all that apply.) -Hypothyroidism -Chronic heart failure -Chronic renal failure -Chronic infections -Adrenal insufficiency
-Chronic renal failure -Chronic infections -Adrenal insufficiency Explanation: Causes of weight loss include gastrointestinal diseases; endocrine disorders (diabetes mellitus, hyperthyroidism, adrenal insufficiency); chronic infections; malignancy; chronic cardiac, pulmonary, or renal failure; depression; and anorexia nervosa or bulimia. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 232. Chapter 13: Assessing Nutritional Status - Page 232
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 -Anorexia -Cirrhosis
-Diabetes -Hypertension -Sleep apnea Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 233. Chapter 13: Assessing Nutritional Status - Page 233
You note that your client has developed mental status changes and paresthesias. What would you know to assess as a possible cause for these changes? Select all that apply. -Patient's hydration status -Patient's intake of protein -Patient's vitamin intake -Patient's BMI
-Patient's hydration status -Patient's vitamin intake Explanation: Note changes in mental status, irritability, inability to concentrate, or paresthesias. Dehydration and lack of vitamins may cause these symptoms. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 227. Chapter 13: Assessing Nutritional Status - Page 227
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 -False
-True Explanation: If a scale is available, the nurse should instruct the client to stand shoeless on the scale with heels together and back straight, looking straight ahead. The nurses then should use the L-shaped measuring attachment on the scale to measure height. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 232. 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. -blood pressure -cholesterol -activity level -temperature -medications
-blood pressure -cholesterol -activity level Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Assessing Nutritional Status, p. 238. Chapter 13: Assessing Nutritional Status - Page 238
