Chap. 13: assessing nutritional status

The nurse provides dietary instructions to a client at risk for hypokalemia about which foods are high in potassium and should be included in the daily diet. The nurse should tell the client that which fruit is highest in potassium? 1.Kiwi 2.Apples 3.Peaches 4.Pineapple

1.Kiwi

The nurse is creating a plan of care for a client receiving enteral feedings via a gastrostomy tube (G-tube). The nurse should plan to include which intervention in the plan of care? 1.Provide oral fluids 3 times per day. 2.Check around the stoma site for skin irritation. 3.Medicate with antidiarrheal medications every day. 4.Use sterile technique when administering the tube feedings.

2.Check around the stoma site for skin irritatio

The nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which intervention should the nurse implement to determine the effectiveness of the tube feedings? 1.Use a calorie count. 2.Obtain a daily weight. 3.Evaluate intake and output. 4.Monitor serum protein level.

2.Obtain a daily weight

At what percent of weight over ideal weight is a person considered obese?

20%

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? 1.Tomato soup 2.Boiled shrimp 3.Instant oatmeal 4.Summer squash

4. summer squash

The nurse is providing dietary instructions to a client about food items that are high in vitamin C. Which food item does the nurse recommend as being highest in vitamin C? 1.Milk 2.Eggs 3.Liver 4.Cabbage

4.Cabbage

The nurse is providing a dietary session to a group of clients about the vitamin content of various foods. The nurse should tell the clients that which food item is highest in vitamin A? 1.Eggs 2.Milk 3.Tomatoes 4.Green leafy vegetables

4.Green leafy vegetables

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? 1.Milk 2.Chicken 3.Broccoli 4.Legumes

4.Legumes

The nurse is teaching a client with tuberculosis about nutrition and foods that should be increased in the diet. The nurse should suggest that the client increase which food items? 1.Potatoes and fish 2.Eggs and spinach 3.Grains and broccoli 4.Meats and citrus fruits

4.Meats and citrus fruits

When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet? 3 1 7 5

5

A client in a long term care facility has lost 5 lbs of body weight in the past month. Which of the following actions should the nurse take to determine the cause of the weight loss? Ask the client to complete a 2-day food diary. Have the client complete a 24-hour food diary. Analyze the client's intake record. Conduct a complete nutrition history.

Analyze the client's intake record.

A client in a long term care facility has lost 5 lbs of body weight in the past month. Which of the following actions should the nurse take to determine the cause of the weight loss? Ask the client to complete a 2-day food diary. Conduct a complete nutrition history. Have the client complete a 24-hour food diary. Analyze the client's intake record.

Analyze the client's intake record. For the client who is in a long-term care facility and is experiencing weight loss, the nurse can utilize the client's intake record to determine daily oral intake. An assessment of caloric and nutritional deficits can be made with this information. Conducting a complete nutritional history would be an inefficient use of time and inappropriate if the client is established at the long term care facility. Asking the client to complete a 24-hour or 2-day food diary would be appropriate only if the client lived at home.

Which defeciency leads to parathesia?

B12

What vitamin defeciency causes a swollen, red tongue?

B12 defeciency

What defeciency is associated with cracks in the side of the mouth?

B3 or niaCin or B

A client with liver cancer receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse should try to limit which food that is most likely to cause this taste for the client? 1.Beef 2.Custard 3.Potatoes 4.Cantaloupe

Beef. cantaloupe is tolerated well.

A nursing student is caring for a male patient who has been admitted in a severely malnourished state. For what signs of malnutrition would the student observe? Cranium that appears larger in proportion to body Bleeding of the gums Liver pain Increased scrotum size

Bleeding of the gums

A nursing student is caring for a male patient who has been admitted in a severely malnourished state. For what signs of malnutrition would the student observe? Increased scrotum size Cranium that appears larger in proportion to body Bleeding of the gums Liver pain

Bleeding of the gums Clinical findings of malnutrition can occur in many places throughout the body. Visible signs include muscle wasting, particularly in the temporal area, and muscle weakness; tongue atrophy; and bleeding or changes in the integrity or hydration status of the skin, hair, teeth, and gums.

The nurse is caring for a client recovering from surgery with an open wound. The nurse should encourage this client to increase the intake of which foods? Citrus fruits and mixed vegetables. Leafy green vegetables and fruit. Whole grains and nut butter. Meat and dairy products.

Citrus fruits and mixed vegetables.

A teenaged client is seen by the nurse for report of excessive thirst and weight loss despite high food intake. Which health condition is most likely responsible for these symptoms? diabetes mellitus hypothyroidism protein deficiency anorexia

Diabetes mellitus, juvenile onset, is characterized by symptoms of excessive thirst (polydipsia) and weight loss despite hunger and high food intake as a result of metabolic changes associated with this condition. Symptoms associated with hypothyroidism include decreased appetite, lethargy, and weight gain. Symptoms associated with protein deficiency often include problems related to quality of skin, hair, and nails. The primary characteristic of anorexia is intentional food restriction.

What should nurse recommend to patient with dumping syndrome?

Do not drink with meal, have several small meals, and eat food with a source of protein as this prolongs digestion and slows passing.

In which disease process should a nurse expect to see a client with the presence of pitting edema? End stage renal disease Diabetes mellitus Liver disease Colon cancer

End stage renal disease

A nurse is working with a client who has just been given a prescription for warfarin (Coumadin). Which foods should the nurse warn this client to avoid due to its interference with the effectiveness of warfarin? Dairy products Green, leafy vegetables Red meat Citrus fruits

Green, leafy vegetables b/c they have vit K, an antidote to warfarin, which would potentially cause blood clots.

A diagnostic finding which is unrelated to nutritional deficiency is High serum albumin Low prealbumin level High 24 hours urine creatinine High lymphocyte count

High serum albumin

A nurse collects nutritional information on a client. Which statement by the client needs to be validated by careful objective data? "I exercise about 30 minutes a day to control my weight." "I eat small amounts of food 5 to 6 times a day." I drink two large bottles of caffeinated beverages every day. "Packing a lunch helps me to control my calorie intake."

I drink two large bottles of caffeinated beverages every day

When teaching a nutrition class, what would you recommend for adults older than the age of 50? Increase foods rich in vitamin B6 and vitamin D Increase foods rich in vitamin B12 and calcium Increase foods rich in vitamin B6 and saturated fats Increase foods rich in vitamin E and folic acid

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 Provide support or hold the client to record the height Obtain this information subjectively from the client Use a standard chart for height by age and gender

Measure the arm span to estimate height

Which statement about weight should a nurse keep in mind when evaluating a client's nutritional status? Fat distribution is not as important as the overall amount Subtle deviations from the normal ranges are to be expected Muscle, bone, fat, and fluid can account for excessive weight Obesity is classified as being 10% over ideal body weight

Muscle, bone, fat, and fluid can account for excessive weight

You note that your patient has developed mental status changes and paresthesias. What would you know to assess as a possible cause for these changes? Patient's vitamin intake Patient's hydration status Patient's intake of protein Patient's BMI

Patient's hydration status

An young adult female presents at the clinic with fatigue and long, heavy periods. Blood is drawn for laboratory testing, and findings include both low hemoglobin and hematocrit levels. What can these low levels indicate? Poor iron absorption Decreased calcium level Fluid deficit High-folate level

Poor iron absorption

Riboflavin or B2 defeciency leads to

Riboflavin=redish purple tongue, cheeks, and eyes.

A nurse is conducting a comprehensive nutritional assessment on a patient with suspected malnutrition. Why would it be important to assess this patient's ability to cook? To evaluate the patient's food preferences To determine if the patient is interested in preparing nutritious food To determine the patient's understanding of the principles of nutrition To assess if the patient has the ability to obtain or prepare food

To assess if the patient has the ability to obtain or prepare food

Which defeciency leads to bowed legs?

Vit D leading to ricketts disease

During a physical assessment, a client reports he has had an inflamed sore on his arm for 2 weeks with no signs of healing. The nurse notes the client also has bleeding gums. What do these findings suggest regarding the client's nutritional status? Vitamin C deficiency Vitamin D deficiency Vitamin B12 deficiency Vitamin A deficiency

Vitamin C deficiency

During a physical assessment, a client reports he has had an inflamed sore on his arm for 2 weeks with no signs of healing. The nurse notes the client also has bleeding gums. What do these findings suggest regarding the client's nutritional status? Vitamin B12 deficiency Vitamin D deficiency Vitamin A deficiency Vitamin C deficiency

Vitamin C deficiency. delayed wound healing and bleeding gums=vit C def.

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 Triceps skinfold measurement Mid-arm muscle circumference Mid-arm circumference

Waist circumference

A nurse is conducting a health history interview for an older adult. Which of the following questions or statements would be important for nutritional assessment?

What kind of over the counter medications do you take?

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 a client with a body mass index of 23 and high LDL cholesterol a client with body mass index of 18.5 and family history of heart disease a client with a body mass index of 25 and normal HDL cholesterol

a client with body mass index of 27 and blood pressure of 145/80 mm Hg

What should a patient with cirrhosis eat?

a. grilled chicken b. fish sticks--high in fat because they are fried. c. potato soup--high in sodium, which could cause ascites d. baked ham--high in sodium

While conducting a physical examination, the nurse notices the client's mucous membranes are pale in color. Which nutritional deficiency is most likely for this client? vitamin A vitamin C protein anemia

anemia Pale mucous membranes are common in anemia due to decreased blood flow and/or red blood cells in the body. Vitamin A deficiencies are most likely if the signs and symptoms include petechiae, ecchymoses, or poorly healing sores. A protein deficiency is most likely if there is the presence of edema, abdominal distension, or muscle wasting. A vitamin C deficiency is most likely if the client reports muscle and joint pain, bleeding gums, or poorly healing wounds.

Vit B defeciency causes what?

anemic, dry, flaky skin

A nursing student is caring for a male patient who has been admitted in a severely malnourished state. For what signs of malnutrition would the student observe?

bleeding gums

During an assessment the nurse suspects that a client has a vitamin C deficiency. What information did the nurse use to make this clinical determination? paresthesias bleeding gums dry flaky skin bone pain

bleeding gums A manifestation of vitamin C deficiency are bleeding gums. Bone pain is associated with a vitamin D deficiency. Paresthesias are associated with vitamin B12, pyridoxine, or thiamine deficiency. Dry flaky skin is associated with a vitamin A, vitamin B-complex, or linoleic acid deficiency.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1.Broth 2.Coffee 3.Gelatin 4.Pudding 5.Vegetable juice 6.Pureed vegetables

broth, coffee, and gelatin

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? 1.Tea 2.Gelatin 3.Custard 4.Ice pop

custard. other items are clear liquid.

During an assessment the nurse suspects that a client has a vitamin C deficiency. What information did the nurse use to make this clinical determination? bleeding gums dry flaky skin bone pain paresthesias

dry flaky skin

Vit A defeciency causes

dry skin (think retinol) and eye problems

What should a patient with pancreatitis avoid eating.

high fat foods such as ice cream

How does dehydration affect hemocrit?

increases hemocrit because proportion of water in plasma decreases, leaving a higher value.

How does dehydration affect hemoglobin

increases levels as the hemocrit

spoon shaped nails are caused by?

iron defeciency anemia

The nurse is assessing the skin of a client with a history of malabsorption deficiency and discovers brittle nails. What type of nutritional deficiency should the nurse suspect based on this observation? 1.Iron deficiency 2.Protein deficiency 3.Fatty acid deficiency 4.Vitamin K deficiency

iron defeciency. would also cause spooning of nails.

How does dehydration affect albumin

it increases levels because the proportion of water in plasma goes down.

How does low protein cause the distended bellies seen in starving African children?

less plasma proteins to maintain hydrostatic pressure

An older male with a history of consuming an increased amount of processed foods since the death of his wife is complaining of heart palpitations. Which lab result is priority for the nurse to assess?

potassium, not sodium

The nurse is discussing weight loss with a client who has risk factors for heart disease. The client states, "I've tried everything already; I'm not willing to try anything else right now." In which stage of change is this client? contemplation maintenance and relapse prevention precontemplation preparation

precontemplation The client is in the precontemplation stage of the change model. The client is not even considering a change at this time. Clients with obesity may have tried several times to lose weight with limited or no success, and they may have given up. In the contemplation stage, clients are ambivalent about change. The client may be willing to assess both benefits and challenges of the change. In the preparation stage of this model, the client would be preparing to embark on the change process. In the maintenance and relapse prevention stage of the model, the client is incorporating the new behavior over the long term

The nurse is preparing to measure the triceps skinfold of an adult client. The nurse should

repeat the procedure three times and average the measurements. Explanation: To measure triceps skin fold thickness (TSF), instruct the client to stand and hang the nondominant arm freely. Grasp the skin fold and subcutaneous fat between the thumb and forefinger midway between the acromion process and the tip of the elbow. Pull the skin away from the muscle (ask client to flex arm: if you feel a contraction with this maneuver, you still have the muscle) and apply the calipers. Repeat three times and average the three measurements.

A patient describes probable night blindness. Intake of what vitamin should be evaluated? B D C A

vitamin A

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? Iodine Niacin Thiamine Vitamin B

vitamin B12 cobalamine

In her assessment of a client, a nurse finds that the client has soft, spongy, and bleeding gums. The nurse recognizes that this client most likely has a deficiency in which of the following? Iron Vitamin C Vitamin B12 Protein

vitamin C Soft, spongy, and bleeding gums are a sign of vitamin C deficiency. Iron deficiency is associated with spoon-shaped, brittle, or rigid nails. Vitamin B12 deficiency is associated with a beefy, red tongue. Protein deficiency is associated with thinning, dry hair, edema, and ascites