Chapter 13: Assessing Nutritional Status

Cachexia is characterized by a highly catabolic state with accelerated muscle loss. What is the other component of cachexia?

-Chronic inflammatory response

In which disease process should a nurse expect to see a client with the presence of pitting edema?

-End stage renal disease

A male client who was transferred from intensive care and extubated less than 24 hours ago exhibits drooling and a weak voice. At meal time, what is the nurse's priority action?

-Explain to the client why he should not eat anything by mouth yet.

Upon assessment, the nurse determines the patient has a body mass index (BMI) of 45. This finding indicates the patient is which of the following?

-Extremely obese

Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease?

-Females with 88.9 cm (35 in) or greater waist circumference.

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

What can cause edema in a patient with a weak heart?

-Overhydration

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

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

-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?

-Vitamin B

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. Use a standard chart for height by age and gender B. Measure the arm span to estimate height C. Obtain this information subjectively from the client D. Provide support or hold the client to record the height

Measure the arm span to estimate height

The nurse might expect the patient admitted with dehydration to have tachycardia.

True

A nurse working at a health clinic performs nutritional assessments on a variety of clients in one day. Which of the following clients would be at increased risk for malnutrition? Select all that apply. A. A 12-year-old girl with Crohn's disease B. A teenaged girl who typically snacks on carrots and apple slices C. A single mother of three who makes $20,000 per year D. A 33-year-old smoker who says that food has lost its taste E. A 45-year-old man who regularly works 8-hour days F. An elderly woman with Alzheimer's disease

• A 12-year-old girl with Crohn's disease • A single mother of three who makes $20,000 per year • A 33-year-old smoker who says that food has lost its taste • An elderly woman with Alzheimer's disease

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. A. Marking pencil B. Balance beam scale with height attachment C. Skinfold calipers D. Sphygmomanometer E. Metric measuring tape F. Stethoscope

• Balance beam scale with height attachment • Metric measuring tape • Marking pencil • Skinfold calipers

A nurse is assessing the hydration status of a young client with a high temperature. Which interventions should the nurse implement in this case? Select all that apply. A. Inspect tongue condition B. Observe skin moisture C. Check skin turgor D. Palpate radial pulse E. Assess the nails

• Check skin turgor • Observe skin moisture • Inspect tongue condition • Palpate radial pulse

A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply. A. Diabetes B. Anorexia C. Cirrhosis D. Sleep apnea E. Hypertension

• Diabetes • Hypertension • Sleep apnea

A nurse is describing the importance of fats to the diet to a client. Which of the following functions of fat in the body should the nurse mention? Select all that apply. A. Lubricating skin to slow water loss B. Insulating skin and nerve fibers C. Raising blood glucose levels D. Protecting internal organs E. Making hormones such as insulin

• Insulating skin and nerve fibers • Protecting internal organs • Lubricating skin to slow water loss

A nurse is instructing a client on the importance of protein in the diet. Which of the following should the nurse mention as functions of proteins in the body? Select all that apply. A. Helping transport oxygen and lipids through the circulatory system B. Making hormones such as insulin C. Acting as enzymes for chemical reactions such as digestion D. Raising blood glucose level E. Serving as the primary energy source for the body

• Making hormones such as insulin • Acting as enzymes for chemical reactions such as digestion • Helping transport oxygen and lipids through the circulatory system

Which nutritional data obtained from a client needs validation by a nurse?

-"My rings are not fitting on my fingers like they usually do"

A nurse is assessing the nutritional status of an elderly client. Which of the following tools would be best for the nurse to use for this client?

-Mini nutritional assessment (MNA-SF)

When would a nurse obtain a mid-arm circumference measurement?

-To provide percentage of body fat and muscle tissue.

Which measurement should the nurse add to the body mass index to increase the predictive ability for the client?

-Waist circumference

A patient has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply. A. medications B. activity level C. cholesterol D. blood pressure E. temperature

• activity level • cholesterol • blood pressure

A nurse collects nutritional information on a client. Which statement by the client needs to be validated by careful objective data?

-"I drink two large bottles of caffeinated beverages every day."

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."

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 prescribed and over-the-counter medicines do you take?"

To calculate the ideal body weight for a woman, the nurse allows

-100 pounds for 5 feet of height.

A nurse is calculating the ideal body weight for a female client who 5 feet 5 inches and has a medium body frame. Which of the following is this client's ideal body weight?

-125

A nurse is working with a patient whose ideal body weight is 130 lb. At what weight would this client first be considered overweight?

-143lb

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

The nurse caring for a hosptalized client suspects inadequate food intake. The dietician is consulted to conduct a calorie count. How should the nurse document the client's breakfast intake?

-2 slices of bacon eaten

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

-20%

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?

-24.4

A nurse is measuring an adult male client's mid-arm circumference (MAC) as part of the overall assessment of the client's nutritional status. Which of the following is the standard reference for the MAC for an adult male?

-29.3 cm

An individual is considered obese when his or her BMI is:

-30-39

A nurse is advising a 40-year-old male client on his dietary fiber intake. Which of the following should the nurse indicate would be an adequate total fiber intake per day?

-38 grams

A waist circumference of greater that which of the following is indicative of excess abdominal fat in men?

-40

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?

-46

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 patients in an outpatient setting. Which of the following patients is most likely to experience a weight gain?

-A 33-year-old athlete on steroids

The nurse conducting a nutritional assessment should notify the healthcare provider of a possible eating disorder based on which finding?

-Absence of menstrual periods

The nurse is reviewing a client's medical history before surgery. The client has been taking ginseng, garlic, and aspirin daily. What's the nurse's best action?

-Advise the client to notify his or her healthcare provider about stopping the supplments and aspirin.

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 of the gums

Waist circumference guidelines may not be accurate for adult clients who are shorter than 152.4 cm (5 ft) in height. This restriction is also a concern for which other anthropometric measurement?

-Body mass index (BMI).

A nurse is working with a client with a chronic disease that has contributed to the client developing cachexia, a type of malnutrition. As a result, the client demonstrates abnormal metabolic rate, anorexia, muscle wasting, severe weight loss, and general decline in condition. Which chronic disease, strongly associated with cachexia, does the client most likely have?

-Cancer

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

A nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present?

-Chronic dieting

A middle aged client is admitted to the observation unit with right lower quadrant pain. The client has not kept down any food or drink for 24 hours. The client's temperature is 38.6°C orally (101.5°F). The client describes the pain as "achy with periods of sharp, stabbing sensations." What would be the most appropriate nutritional nursing diagnosis for a client with these assessment data?

-Fluid volume less than body requirements related to an inability to tolerate fluids

Dietary guidelines established by the United States Department of Health and Human Services and the United Stated Department of Agriculture consider what factors when developing guidelines? (Mark all that apply.) A. Gender B. Age C. Weight D. Activity levels E. Height

-Gender -Age -Physical Activity levels

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?

-Green, leafy vegetables

A teenage client with cancer asks the nurse what hair is made of. What would be the nurse's best answer?

-Hair consists mostly of protein

What is the use of dietary assessment data gathered from a client by a nurse?

-Identify patient outcomes

A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states her appetite has been low for the past 3 months with a 20 pound weight loss. Which nursing diagnosis should the nurse confirm based on this data?

-Imbalanced Nutrition

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 is working with a client who is Buddhist. Based on what the nurse knows of the common dietary practice of this religion, which nutrient should the nurse make sure that the client is not deficient in?

-Iron

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?

-Meat and dairy products.

You are the clinic nurse assessing a new patient that has come in to see a physician. The assessment data that you collect reveals that the patient 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

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 nurse obtains a height measurement on an elderly client and notes that the height has decreased from 5 years ago. What is an appropriate action by the nurse?

-Record this measurement in the client's chart and alert the health care provider

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 patient?

-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

The nurse in a bariatric clinic is providing education to a patient who wishes to lose weight. The nurse informs the patient that she has a Body Mass Indicator of 45. What does this indicate?

-The patient is extremely obese

What is the most common measurement used to determine abdominal visceral fat?

-Waist Circumference

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

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

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.