Adult Health Ch. 5

Which diagnostic findings indicates nutritional balance?

High serum albumin

Using the assessment technique depicted in the accompanying photo, the examiner would assess which of the following structures?

Liver

What is the body mass index (BMI) of a client who weighs 195 lbs and is 6 feet tall? Round to the nearest whole number, and enter the correct number ONLY.

26

An individual is considered obese when their BMI is what value?

30-39

A nurse determines that a male patient has an increased risk for diabetes, heart disease, and hypertension based on the patient's waist circumference. Which waist circumference measurement would lead the nurse to suspect this?

41 inches

When calculating ideal body weight for women, the health care professional adds how many pounds for each inch of height over 5 feet?

5

An adolescent female client presents to the primary care clinic for a routine sports physical. Which nutritional components will the nurse recognize as a greater risk of being decreased in this population? Select all that apply.

Folate Iron Calcium

The nurse is completing a physical examination of a group of clients. What client situation is the nurse most likely to use percussion during the assessment?

The client who presents with a respiratory rate of 22 and a productive cough and reports shortness of breath when climbing stairs

A very thin woman seeks medical care. During assessment of this client, the nurse determines the need for a nutritional assessment. Which of the following components will the nurse include in this assessment? Select all that apply.

Thyroid gland Oral mucosa Ratio of body weight and height

A new client walking in to the health care center is actively wheezing and reports frequent episodes of wheezing. Based on the client's responses during the interview, the nurse suspects the client has a variety of food allergies. What nutritional assessment method should the nurse include in the plan of care?

A 3- to 7-day food record

While collecting the client profile information, the client admits to crying everyday after working 8 hours in a factory. This finding reflects what part of the profile?

Coping strategies

Which statement made by the nurse indicates that the nurse is performing a holistic health history versus a traditional health or medical history?

"How has the stroke affected your ability to perform your daily activities?"

The nurse is assessing the patient's pain. Which question asked by the nurse is considered an open-ended question?

"Describe the pain."

After educating a client on MyPyramid recommendations, the nurse realizes more education is needed when the client makes which of the following remarks?

"I need to do at least 15 minutes of physical activity one day a week."

A nurse is documenting a patient's chief complaint/reason for seeking care in the medical record. Which of the following would be MOST appropriate?

"My head feels like it is about to explode."

Which observation made by the nurse reflects the first fundamental technique used in physical examination?

"Patient appears older than stated age."

Which statement made by the nurse would be a nontherapeutic response when the patient says, "I will not take pain medication when I am in pain"?

"Refusing medication can only hurt you by increasing your awareness of the pain experience."

Which prompt by the nurse is most appropriate to obtain educational or occupational information?

"Tell me about your job."

Two nursing students are role-playing a client assessment situation. One of the students is acting as the nurse, and the other student is acting as the client. The task is to focus on assessing the client's lifestyle. Which question would be most appropriate for the student acting as the nurse to ask?

"What do you usually do for fun?"

A nurse is preparing to obtain the health history of an older adult client. Which question posed by the nurse best focuses the clinical evaluation of the older adult client?

"What interferes most in your daily activities?"

A waist circumference greater than which value indicates excess abdominal fat in men?

101.60 cm (40 in)

While undergoing a health history and physical assessment, a patient states, "I'm really afraid this pain in my belly is cancer." Which response by the nurse would be MOST appropriate?

"You seem upset about the pain. Tell me what's happening."

To calculate the ideal body weight for a woman, the nurse allows for which of the following? To calculate a woman's ideal body weight, the nurse allows 100 lb for 5 ft of height and adds 5 lb for each additional inch over 5 ft.

100 lb for 5 ft of height

The nurse observes a serum albumin level of 2.50 g/dL in an older adult patient who lives at home alone. What does this level likely indicate?

A severe protein deficiency

The nurse is discussing lifestyle changes and weight reduction with a female client with excessive abdominal fat. What is the method the nurse will use to measure the client's waist circumference?

A tape measure is placed in a horizontal plane around the abdomen at the level of the iliac crest.

A nursing student is learning to complete a focused abdominal assessment. She understands the necessity for altering the assessment skill sequence when examining this body region. Therefore, she will complete which skill after inspection?

Auscultation

A nurse determines that a patient has poor nutrition based on which assessment finding?

Beefy-red tongue

A patient arrives at the clinic for an evaluation. This is the first time the patient is being seen. Which information would the nurse need to obtain first?

Biographical data

Which area for assessing the client profile should be addressed last?

Body image

A nurse is preparing to conduct a health assessment with a 78-year-old man who wears a hearing aid in his left ear. The patient is accompanied by his wife. Which of the following would be most appropriate?

Check to make sure that the patient has his hearing aid turned on and in place in his left ear.

A nurse is obtaining family history from a patient. Which of the following would be LEAST helpful to use when documenting this information?

Checklist

When obtaining a health history from a patient, what should be the nurse's primary focus? (Select all that apply.)

Current and past medical problems Family history A comprehensive body systems review

When the nurse is percussing for measurement of the patient's liver span, what type of response should be heard?

Dull sound

During a nutritional assessment, the nurse measures a woman's waist at 38.5 inches (98 cm). Based on this finding, which of the following is a priority intervention?

Educate the client regarding her increased risk for hypertension and diabetes.

What would be important for the nurse to consider at the beginning of an interview?

Establish rapport with the client and family members

A community health nurse goes on a first home visit to complete a home safety assessment. Which of the following components will be part of the nurse's home safety assessment? Select all that apply.

Hard wood floors in the dining room ABC fire extinguisher in the kitchen pantry Motion light on the porch

What does the patient have the right to know about the data collected by the nurse? (Select all that apply.)

How the information will be used Why the information is being obtained Whether the information will be held in confidence

The nurse is assessing a client's abdomen and percusses a large area of dullness on the right side of the abdomen, not the expected tympany. What has the nurse percussed?

Liver

A client has monthly laboratory tests done. The nurse notes a decrease in the albumin level. What condition in the client's history could alter the albumin level?

Liver disease

Which nursing measure should be considered when performing a physical examination of a client using the inspection technique?

Maintain standard precautions.

What should the nurse do when caring for a client with alcoholism who is diagnosed with Imbalanced Nutrition: Less than Body Requirements?

Obtain a baseline weight

Hyperresonance is audible when which area is percussed?

Overinflated lung tissue

A male client in a wheelchair comes in for his yearly physical examination. He is unable to stand. The nurse retrieves the wheelchair scale to obtain an accurate weight. The nurse understands the importance of this assessment with this client. What is the nurse's reasoning for obtaining an accurate weight?

People with disabilities have an increased incidence of obesity.

The nurse notes hyperresonance over inflated lung tissue when performing a physical assessment on a patient with emphysema. What process does the nurse use for this assessment?

Percussion

A client with chronic obstructive pulmonary disease (COPD) visits the health care center with breathing difficulties. Which part of the client profile relates to the client's view of himself or herself and the impact of COPD?

Self-concept

During a health history, a nurse asks a patient, "How do you feel about your life in general?" The nurse is assessing which of the following?

Self-concept

The nurse is preparing the client file for an 8-year-old child. The child's mother informs the nurse that the child has difficulty breathing at night and makes a whistling sound while sleeping. Because of the child's age, her mother continues to provide the child's health history to the nurse. Which action by the nurse demonstrates that the nurse understands the importance of collecting a client's health history?

The nurse continues to collect information from the child's mother, knowing the informant will not always be the client.

The emergency department (ED) nurse demonstrates the proper abdominal assessment technique in which scenario?

The nurse protects client privacy while visually inspecting the abdomen, warms the stethoscope before listening for bowel sounds, uses the fingertips to lightly palpate the four abdominal quadrants, and taps the four abdominal quadrants.

During the initial physical examination, a client's pulse rate was 71 beats per minute (bpm). Four hours later on reassessment, the pulse rate was 40 bpm. How should the nurse proceed?

Thoroughly assess the client; then notify the physician.

When examining a patient's abdomen, the nurse percusses over the stomach. Which of the following would the nurse expect to elicit?

Tympany

Which of the following questions would identify a client's chief complaint?

What brought you to the emergency department?

The nurse is reviewing the laboratory test results of a patient who is suspected of having a nutritional deficiency. Which of the following would the nurse identify as helping to support this diagnosis?

low serum albumin levels

At which body mass index (BMI) value are patients considered to have increased risk for problems associated with poor nutritional status?

lower than 18.5