Chapter 5: Adult Health and Nutritional Assessment 2
Overinflated lung tissue
Hyperresonance is audible when which area is percussed?
Liver disease
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
Using the assessment technique depicted in the accompanying photo, the examiner would assess which of the following structures?
"A trust and belief in a higher power or something you cannot see"
A hospice nurse is discussing spirituality and faith with a client and the client's family member. The client asks the nurse what is the difference between spirituality and faith. How will the nurse describe faith?
Beefy-red tongue
A nurse determines that a patient has poor nutrition based on which assessment finding?
23
A nurse is reviewing the medical records of several patients and their risk for health problems. The nurse determines that the patient with which body mass index (BMI) would have the lowest risk?
Oral mucosa Thyroid gland Ratio of body weight and height
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.
101.60 cm (40 in)
A waist circumference greater than which value indicates excess abdominal fat in men?
Hypertension Cardiovascular disease Diabetes
Assessment of a female client reveals a waist circumference of 37 inches (94 cm). Based on this finding, the nurse develops a teaching plan for the client to reduce her risk for which of the following? Select all that apply.
lower than 18.5
At which body mass index (BMI) value are patients considered to have increased risk for problems associated with poor nutritional status?
The nurse continues to collect information from the child's mother, knowing the informant will not always be the client.
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 recognizes that the client's obesity may be specifically related to the endocrine disorder. The nurse performs a thorough nutritional assessment.
The nurse observes that a client's medical report indicates that the client has Cushing syndrome. During inspection, the nurse notes that the client's BMI is 31, waist circumference is 40 inches, and localized fat pads exist around the neck and upper part of the back. Which of the following must the nurse keep in mind while planning the client's care?
100 lb for 5 ft of height.
To calculate the ideal body weight for a woman, the nurse allows
100 lb for 5 ft of height
To calculate the ideal body weight for a woman, the nurse allows for which of the following?
5
When calculating ideal body weight for women, the health care professional adds how many pounds for each inch of height over 5 feet?
Current and past medical problems A comprehensive body systems review Family history
When obtaining a health history from a patient, what should be the nurse's primary focus? (Select all that apply.)
Dull sound
When the nurse is percussing for measurement of the patient's liver span, what type of response should be heard?
Percussion
Which method of physical examination refers to the translation of physical force into sound?
Maintain standard precautions.
Which nursing measure should be considered when performing a physical examination of a client using the inspection technique?
"Refusing medication can only hurt you by increasing your awareness of the pain experience."
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"?
