Chronic: Exam 2: Chapter 5: PREP U
which BMI value are patients considered to have an increased risk for problems associated with poor nutritional status?
lower than 18.5
what nursing measure should be considered when performing a physical exam on a client using the inspection technique?
maintain standard precautions
hyperresonance is audible when which area is percussed?
over-inflated lung tissue
what is the importance of obtaining an accurate weight in a client who is in a wheelchair
people with disabilities have increased incidence of obesity
the nurse notes hyperresonance over inflated lung tissue during assessment on a patient with emphysema. what process does the nurse use for this assessment?
percussion
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
factor that most strongly influences success of percussion
quick striking
when percussing the client's chest wall, the nurse expects to hear
resonant sounds
what body system will the nurse examine first during the physical examination?
skin
when conducting the initial observations during a physical assessment, what would the nurse be LEAST likely to include?
- percussion of the lungs - palpation of the abdomen
when assessing a client who has a draining wound, the nurse should be alert for what nutritional consequences?
- protein loss - electrolyte loss - mineral loss
for a very thin woman seeking medical care, what components will the nurse include in her nutritional assessment?
- ratio of body height and weight - oral mucosa - thyroid gland
when calculating ideal body weight for women, the health care professional adds how many pounds for each inch of height over 5 feet?
5
this is the first time the patient is being seen, what information would the nurse need to obtain first?
biographical data to help put the patient's health history into context
what is the last area to be addressed when assessing the client profile?
body image
what statement made by the nurse best assesses the client for medication interaction?
"can you please tell me what each of your medications are for?"
which question would help the nurse gather information about a client's lifestyle that may be a factor in the client's present illness?
"how many cups of coffee do you drink a day?"
additional education is needed about MyPyramid when the client makes what remark?
"i need to do at least 15 mins of physical activity one day a week"
what question posed by the nurse best focuses the clinical evaluation of the older adult client?
"what interferes most in your daily activities?"
a nurse is performing a physical assessment on the client. what questions will the nurse ask to best assess the client's self-concept?
- "what concerns do you have about your body?" - "how do you feel about your life in general?"
what are some components of a nurse's home safety assessment?
- ABC fire extinguisher in the kitchen - motion light on the porch - hard wood floors in the dining room
a new client has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment. what assessment parameters should the nurse include?
- BMI - clinical examination findings - dietary data NOT - coping strategies
when obtaining a health history from an older adult patient, what should the nurse remember to do?
- ask questions slowly, directly, and in a voice loud enough to be heard by those who are hearing impaired - clarify the frequency, severity, and history of signs and symptoms of the present illness - conduct the interview in a calm, unrushed manner using eye contact
proper sequence for data collection
- chief complaint - present health concern - past health history - family history - review of systems
what does the patient have the right to know about data collected by the nurse?
- how the information will be used - why the information is being obtained - whether the information will be held in confidence
what does the patient have the right to know about the data collected by the nurse?
- how the information will be used - why the information is being obtained - whether the information will be held in confidence
normal steps of physical assessment
- inspection - palpation - percussion - auscultation
an adolescent female client is at risk of having which decreased nutritional components
- iron - folate - calcium
during a health history, what components should the nurse include
- marital status - childhood illnesses - current medications
when assessing a client with a draining wound, the nurse is alert for what nutritional consequences?
- mineral loss - electrolyte loss - protein loss
thin woman seeks medical care, what components will the nurse include in her nutritional assessment?
- oral mucosa - ration of body weight and height - thyroid gland
actions that demonstrate an understanding of HIPPA
- the hospital allows the client to view his or her electronic medical record at the bedside - the hospital provides a copy of the medical record to the client - the client requests a correction to the medical record on file - the nurse informs the client that the therapist will have access to his electronic medical record
nurse is percussing on a client during an exam. what terms should the nurse use when documenting the results?
- tympany - resonance - flatness - dullness
proper sequence for data collection during health history
1. chief complaint (reason for seeking care) 2. present health concern 3. past health history 4. family history 5. review of systems
to calculate the ideal body weight for a woman, the nurse allows
100 lb for 5 ft of height
a nurse is reviewing the medical records of several patients and their risk for health problems. the nurse determines that the patient with which BMI would have the lowest risk?
23
what is the mypyramid recommendation for daily milk intake
3 cups
an individual is considered obese when their BMI is what value?
30-39
waist circumference in men indicating excess abdominal fat
40 inches (101.6 cm)
what does a serum albumin level of 2.50 g/dL indicate?
a severe protein deficiency
what is the best way for a nurse to prepare materials for a client in order to provide culturally appropriate teaching?
access a government-sponsored website that provides culturally appropriate food guides
nurse determines that patient has poor nutrition based on what assessment finding
beefy-red tongue
a nurse is obtaining family history from a patient, what would be LEAST helpful to use when documenting this information?
checklist
what type of response should be heard when percussing the patient's liver span?
dull sound
why should the nurse be empathetic when caring for a client?
empathy helps the nurse become effective while remaining detatched
what is NOT a major food group
fats
what diagnostic finding indicates nutritional balance?
high serum albumin
what priority factor regarding the patient may help the physician arrive at a diagnosis?
history of present illness
while assessing a client's abdomen, the nurse percusses a dull sound, not the expected tympany. the nurse realizes she has assessed what?
liver
what condition in the client's history could alter the albumin level?
liver disease
diagnostic finding that is indicative of a protein deficiency in adults
low serum albumin
a positive nitrogen balance indicates what?
tissue growth
a positive nitrogen balance indicates which condition?
tissue growth
when examining a patient's abdomen, the nurse percusses the stomach. what noise does the nurse expect to hear?
tympany
when percussing a patient's abdomen, the nurse knows that what sound indicates tissue with the LEAST density?
tympany
which sound indicates tissue with the least density?
tympany