Health assessment ch.8
The nurse is preparing to perform a nutritional assessment of a newly admitted client. Which of the following questions would be most appropriate to use when initiating the assessment?
"Can you tell me what you've eaten in the last 24 hours?"
During a new client's nutritional assessment, the nurse asks the client's height and usual weight. The client states that he has no idea how much he weighs. How should the nurse respond?
"Do you feel like your weight has increased, decreased, or stayed the same lately?"
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."
Parents of a 15 month old state they are worried about the rolls of fat on the toddler's thighs; so they have switched him over to skim milk. What is the nurse's best response?
"Whole milk is recommended until age 2."
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 The BMI is calculated by dividing weight in pounds by height in inches squared and then multiplying by 703. The body mass index calculated by the nurse should be approximately 46 for a client who is 6 feet 1 inch (73 inches) tall and 350 pounds
A patient describes probable night blindness. Intake of what vitamin should be evaluated?
A
A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status?
Accessibility The older adult client who is unable to drive will have limited access to a range of foods that will promote nutritional health. The correct option is accessibility. Food preparation seeks to determine who does the cooking for the client and the way in which the foods are prepared. Finances refers to having access to sufficient funds to purchase foods that support nutritional health. Food preferences are personal for each client and refer to likes or dislikes. In addition, the client may report foods they find harmful or beneficial and cultural or religious preferences in this assessment area.
The RN may delegate which care component to a nursing assistant?
Ambulation assistance The RN may delegate individual components of care but does not delegate the nursing process itself. The main functions of assessment, planning, evaluation, and nursing judgment cannot be delegated. For example, if the nurse delegates taking vital signs to a nursing assistant, he or she is responsible for making sure that the data is accurately collected and for following up if findings are abnormal. The nursing assistant may collect vital signs, but the RN is responsible for evalutation. Assessment is always the RN's responsibility, which includes wound assessment and assessing pain level.
A group of students is reviewing information about general indicators for nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator for good nutritional status?
Brittle hair
A nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present?
Chronic dieting Chronic dieting, especially with fad diets, can predispose an individual to malnutrition because the amount of needed nutrients is often lacking in an effort to lose weight quickly. Single parenthood is not a risk factor for malnutrition unless the parent is unable to gain access to shopping or suffers form a lower socioeconomic status. Diabetes mellitus is a chronic disease, not a lifestyle behavior. Excessive exercising may lead to weight loss but not malnutrition.
You are caring for a patient with hypertension. What dietary change would be appropriate to recommend?
Eat more spinach
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
In planning to meet the nutritional needs of a critically ill patient in the intensive care unit, which factor will increase the patient's basal metabolic rate?
Infection
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? A. Patient's BMI B. Patient's hydration status C. Patient's vitamin intake D. Patient's intake of protein
Patient's hydration status
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 hydration status Note changes in mental status, irritability, inability to concentrate, or paresthesias. Dehydration and lack of vitamins may cause these symptoms.
Malnutrition can be too much or too little nutrition. What can malnutrition do in the human body?
Prolong confinement to bed Malnutrition interferes with wound healing, increases susceptibility to infection, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of patients to bed. Therefore options A, B and C are incorrect.
Which of the following problems results from a deficiency in vitamin D?
Rickets
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 Vitamin D is obtained through exposure to sunlight. Some people who are not exposed to enough sun may require dietary supplements. Folate can be found in fortified breads, lentils, and orange juice.
A nurse is providing care for a patient who has a history of alcoholism. What would be appropriate to include in this patient's discharge teaching?
To increase fruit and vegetable intake
The nurse might expect the patient admitted with dehydration to have tachycardia. - True OR - False
True
When beginning a height measurement on a 14-year-old, the nurse should instruct the patient to stand on the scale with his back to the wall. - False OR - True
True
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
What is the most common measurement used to determine abdominal visceral fat?
Waist circumference.
What is the most common measurement used to determine abdominal visceral fat?
Waist circumfrence
Foods rich in iron include all of the following except:
milk
A teenage client with cancer asks the nurse what hair is made of. What would be the nurse's best answer? A. "Hair consists mostly of cellular waste." B. "Hair consists mostly of inorganic matter." C. "Hair consists mostly of protein." D. "Hair consists mostly of carbohydrates."
"Hair consists mostly of protein."
During a new client's nutritional assessment, the nurse asks the client's height and usual weight. The client states that he has no idea how much he weighs. How should the nurse respond? A. "Has your weight increased, decreased, or stayed the same lately?" B. "How would you describe your feelings around your body type and body mass?" C. "Why do you feel that it's not important to monitor your weight?" D. "Can you tell me what you eat and drink in a typical day?"
"Has your weight increased, decreased, or stayed the same lately?"
Parents of a 15 month old state they are worried about the rolls of fat on the toddler's thighs; so they have switched him over to skim milk. What is the nurse's best response? A. "Whole milk is recommended until age 2." B. "You should start seeing some weight loss while he's drinking the skim milk." C. "As he starts walking more, he will develop more fat rolls." D. "You should transition to skim milk by giving him 2% milk first."
"Whole milk is recommended until age 2."
Parents of a 15 month old state they are worried about the rolls of fat on the toddler's thighs; so they have switched him over to skim milk. What is the nurse's best response?
"Whole milk is recommended until age 2." Infants, children, and adolescents require different nutrients based on developmental and growth factors. For example, fat intake is crucial to brain development in infants and young toddlers. Therefore, whole milk is recommended for children younger than 2 years.
A nurse is helping a sedentary 20-year-old female determine her dietary needs. Which of the following would be her estimated calorie needs per day?
1,800-2,000
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 Ideal body weight for a female is 100 lb for 5 ft + 5 lb for each inch over 5 ft plus or minus 10% for small or large frame. For this female client with a medium frame, the formula would be as follows: 100 lb + 25 lb = 125 lb.
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? A. 20 BMI B. 21 BMI C. 19 BMI D. 22 BMI
19 BMI
An individual is considered obese when his or her BMI is: A. 30-39 B. 25-29 C. Less than 24 D. Greater than 40
30 - 39
An individual is considered obese when his or her BMI is:
30-39
When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet?
5 When calculating ideal body weight for women, add 5 pounds for each additional inch over 5 feet.
A patient is interested in losing 15 pounds, and she informs the nurse she is counting her calorie intake each day. The patient has a goal of losing 1 pound a week until she reaches her goal. The patient asks the nurse how many calories she should decrease daily to lose a pound a week. What is the nurse's best response? A. 500 calories/day B. 300 calories/day C. 200 calories/day D. 400 calories/day
500 calories/day
A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. After determining the client's venous filling and emptying each take approximately 10 seconds, the nurse would perform further assessments related to what health problem? A. Ascites B. Fluid volume deficit C. Malnutrition D. Third spacing
Fluid volume deficit
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
A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states that her appetite has been low for the past 3 months, and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this data? A. Imbalanced nutrition B. Fluid volume, excessive C. Knowledge deficit D. Activity intolerance
Imbalanced nutrition
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 Nails are strong; is the documentation that represents a normal finding. Clothing that is too largemight indicate weight loss. Thin, oily hair is not generally a normal finding, nor are white patches on the oral mucosa.
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? A. Obese B. Overweight C. Underweight D. Average weight
Obese
How can a nurse best assess a client's dietary habits?
Obtain a 24 hour dietary recall of all foods and fluids consumed
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 hydration status
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 Even reducing weight by 5 to 10% can improve blood pressure and lipid levels reducing the risk of hypertension. A more rapid weight loss is not sustainable and may not lead to long term prevention of hypertension. This would be the case if the patient consumes no more than 500 calories each day. This restricted level of caloric intake could also lead to nutritional deficiencies. A 10% weight reduction over 6 months is recommended. A 20% weight reduction over 6 months could be too severe and lead to nutritional deficiencies and regaining of lost weight, therefore, having little or no long term impact on preventing hypertension. A daily reduction of 100 calories will not meet the goal of a healthy and realistic weight loss which can compromise healthy blood pressure long term
Which measurement should the nurse Which measurement should the nurse add to the body mass index to increase the predictive ability for the client? add to the body mass index to increase the predictive ability for the client?
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 The nurse should add waist circumference to the BMI to increase the predictive ability for health risk to the client of this measure. It helps to determine the extent of abdominal visceral fat in relation to the body fat. The mid-arm circumference helps to assess skeletal muscle mass and fat stores. The triceps skinfold helps to evaluate subcutaneous fat stores. The mid-arm circumference, along with the triceps skinfold measurement, are used in a formula to calculate the mid-arm muscle circumference, which is used to evaluate muscle reserve stores.
A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply. - Cirrhosis - Hypertension - Diabetes - Anorexia - Sleep apnea
- Hypertension - Diabetes - Sleep apnea
As a nursing student you learn that obesity-related risk factors include what? (Mark all that apply.) - Infertility - Androgenicity - Type 1 diabetes - Hypermenorrhea - Polycystic ovarian syndrome
- Infertility - Androgenicity - Polycystic ovarian syndrome
A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply.
-Diabetes -Hypertension -Sleep apnea
A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this patient's ideal weight?
145 lb A general guideline, often called the rule-of-thumb method, determines ideal weight based on height. This formula is as follows: For adult females: 100 lb (for height of 5 ft) + 5 lb for each additional inch over 5 ft For adult males: 106 lb (for height of 5 ft) + 6 lb for each additional inch over 5 ft.
A nurse assesses a 105-pound adult client who is 5 feet 8 inches tall. What is the estimated body mass index (BMI) for this client? A. 22 B. 16 C. 18 D. 20
16
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 The BMI is calculated by dividing weight in pounds and height in inches multiplied by 703. The body mass index calculated by the nurse should be 19 for a client who is 5 feet 5 inches tall. Assuming the same height and different weight, such as 120 pounds, the BMI would be 20, whereas for 126 pounds the BMI would be 21, while for 132 pounds the BMI would be 22. The nurse should obtain the client's weight and height to determine his or her body mass index, which can be calculated regardless of the client's gender.
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
Which of the following measurements of waist circumference would lead the nurse to suspect that a female client is at an increased risk for cardiovascular disease and diabetes?
36
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? A. 29 B. 34 C. 46 D. 52
46
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.
Helping transport oxygen and lipids through the circulatory system Acting as enzymes for chemical reactions such as digestion Making hormones such as insulin
A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states that her appetite has been low for the past 3 months, and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this data?
Imbalanced nutrition The nurse should confirm the nursing diagnosis of imbalanced nutrition because the client has the major defining characteristics of inadequate food intake and weight loss. Fluid volume, excessive cannot be confirmed because even with the excessive urination the client is losing weight and there is no major defining characteristic present. The client made no statement about activity intolerance or that the client does not have enough knowledge to manage the diabetes properly.
The nurse gathers the follow data: complaint of headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature 100.6°F orally. It was noted that the patient had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be
Impaired comfort related to headache and sore throat pain The priority diagnosis is related to the chief complaint of headache and sore throat.
When teaching a nutrition class, what would you recommend for adults older than the age of 50? A. Increase foods rich in vitamin E and folic acid B. Increase foods rich in vitamin B6 and saturated fats C. Increase foods rich in vitamin B12 and calcium D. Increase foods rich in vitamin B6 and vitamin D
Increase foods rich in Vitamin B12 & Calcium
In planning to meet the nutritional needs of a critically ill patient in the intensive care unit, which factor will increase the patient's basal metabolic rate? A. Infection B. Prolonged fasting C. Long periods of sleep D. Advanced age
Infection
You are the nurse caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid? A. Sodium B. Iodine C. Potassium D. Magnesium
Iodine
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
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? A. Carbohydrate B. Fat C. Iron D. Vitamin K
Iron
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 As the client is unable to stand, the nurse should measure arm spam to estimate the height. The nurse may support or hold the client only when the client is required to stand when recording the height. The nurse should have the client stretch one arm straight out sideways to record the height and measure from the tip of the middle finger to the tip of nose and multiply by 2. The nurse should not obtain this information subjectively from the client. A standard table listing heights and weights may be used for calculating body mass index but would not be used to determine the client's height.
What can cause edema in a patient with a weak heart
Overhydration Edema may be secondary to a protein deficiency or overhydration in a patient with a weak heart.
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 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 Functional limitations influence the ability to obtain or prepare food. The nutrition-metabolic pattern involves more than just the nutrients ingested each day. It encompasses aspects such as culture, religion, and geography; food and fluid preferences and dislikes; patterns of eating, digestion, and allergies; shopping resources and skills; and kitchen facilities and food preparation.
What is the most common measurement used to determine abdominal visceral fat? A. Triceps skinfold thickness. B. Waist circumference. C. Subcutaneous fat determination. D. Body mass index.
Waist circumference
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 The client with a body mass index (BMI) of 27 is overweight and has hypertension. The nurse should offer strategies for weight loss to prevent the progression of cardiovascular disease. A client with a BMI of 18.5 borders on normal and underweight. Despite having a family history of heart disease, the client should be discouraged from further weight loss. Other risk factors for heart disease should be identified and treated as necessary. The client with a BMI of 23 is in the normal range; therefore, pursuing weight loss is not indicated. Further monitoring of the LDL cholesterol is warranted, however. The client with a BMI of 25 would be considered on the borderline of the overweight category; however, the HDL cholesterol is normal. Cardiovascular risk associated with the BMI is not higher in the absence of other risk factors.
The nurse conducting a nutritional assessment should notify the healthcare provider of a possible eating disorder based on which finding?
absence of menstural cycle Amenorrhea is a cardinal symptom of eating disorders. Lack of subcutaneous fat with prominent bones, abdominal ascites, and pitting edema are abnormal findings. Reduced albumin level is a sign of cachexia, a highly metabolic state that with accelerated muscle loss that differs from anorexia nervosa.
The nurse might expect the patient admitted with dehydration to have tachycardia.
true
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 A person with a BMI below 18.5 is underweight, a BMI of 25 to 29.9 indicates an overweight individual, a BMI of 30 or greater indicates obesity, and a BMI of 40 or greater indicates extreme obesity.
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. Adults with large visceral fat stores located mainly around the waist (android obesity) are more likely to develop health-related problems than if the fat is located in the hips or thighs (gynoid obesity). These problems include an increased risk of type 2 diabetes, abnormal cholesterol and triglyceride levels, hypertension, and cardiovascular disease such as heart attack or stroke
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 Skinfold calipers are used to measure triceps skinfold thickness to evaluate the degree of subcutaneous fat stores. Body mass index is calculated by first measuring height and weight by means of a balance beam scale with height attachment and then entering these values into a formula. A tape measure is used to measure waist and mid-arm circumferences.
A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply.
Sleep apnea Hypertension Diabetes
The nurse is conducting a nutrition history with a young adult with signs and symptoms of an eating disorder. Which question exemplifies the most effective way for the nurse to ask about body image?
"What would you change about your body, if you could?" As per the nutrition history, the nurse should ask if there is anything that the client would like to change about his or her body in order to identify disturbance of body image. The client should be asked if he or she gathers around a table with others for meals if the nurse is asking about family dietary patterns. The client should be asked how much he or she exercises in one week if the nurse is asking about exercise patterns. The client should be asked how many meals and snacks he or she eats in one day if the nurse is trying to determine a food pattern.
To calculate the ideal body weight for a woman, the nurse allows
100 pounds for 5 feet of height. To calculate the ideal body weight of a woman, the nurse allows 100 pounds for 5 feet of height and adds 5 pounds for each additional inch over 5 feet. The nurse allows 106 pounds for 5 feet of height in calculating the ideal body weight for a man. The nurse adds 6 pounds for each additional inch over 5 feet in calculating the ideal body weight for a man. Eighty pounds for 5 feet of height is too little.
A nurse assesses a 105-pound adult client who is 5 feet 8 inches tall. What is the estimated body mass index (BMI) for this client?
16 The BMI is calculated by dividing weight in pounds by height in inches squared and then multiplying by 703. The body mass index calculated by the nurse should be 16 for a client who is 5 feet 8 inches tall and 105 pounds.
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
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? A. 34.4 B. 18.9 C. 24.4 D. 29.9
24.4
An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following?
28
A nurse is measuring an adult female client's mid-arm circumference (MAC) as part of her overall assessment of the client's nutritional status. Which of the following is the standard reference for the MAC for an adult female?
28.5 cm The standard MAC is based on the client's sex and age. This is a human body composition measurement, which helps to evaluate the client's nutritional status. The standard reference of MAC for an adult female client is 28.5 cm. Ninety percent of the standard reference of MAC in an adult female is 25.7 cm and represents one who is moderately malnourished. The standard reference of MAC is 29.3 cm in adult males. Ninety percent of the standard reference of MAC in adult males is 26.3 cm and represents one who is moderately malnourished.
An individual is considered obese when his or her BMI is:
30-39 Those persons with a BMI of 30 to 39 are considered obese. Persons with a ABMI of less than 24 are risk for problems associated with poor nutritional status. A BMI of 25 to 29 are considered overweight. Those with a BMI of greater than 40 are considered extremely obese.
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 Adequate total fiber intake is 25 grams per day for adult women and 38 grams per day for men
A waist circumference of greater that which of the following is indicative of excess abdominal fat in men?
40 A waist circumference greater than 40 inches for men or 35 inches for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation.
What is the most common indication of nutritional status in infants and children? A. Growth B. Number of wet diapers/day C. Sleep pattern D. Appetite
Growth Reference: p. 146
The nurse analyzes the data obtained from a client's nutritional assessment and develops a health promotion diagnosis related to nutrition for a client. Which of the following would be the best example?
Health-seeking behaviors related to desire and request to alter amount of food intake
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 Be prepared to help adolescent females and women of child-bearing age increase intake of iron and folic acid. Assist adults older than 50 years to identify foods rich in vitamin B12 and calcium. Advise older adults and those with dark skin or low exposure to sunlight to increase intake of vitamin D.
A nurse is caring for a client with nasal infection at the healthcare facility. The dietitian has prescribed a diet rich in Vitamin A for the client. The nurse knows that Vitamin A is important for which of the following reasons?
Maintenance of healthy epithelium
The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding?
Let's discuss your risk factors for heart disease." Waist circumference is an indicator of central body fat. In men, a waist circumference greater than 40 inches (102 cm) is strongly associated with an increased risk for heart disease. High waist circumference alone cannot provide enough information about vitamin deficiency. Other signs and symptoms must be present and further assessment is warranted prior to making this statement. Protein deficiency is associated with abdominal distension and ascites, not high waist circumference. Because waist circumference is a measure of central body fat, it stays consistent over the course of the day.
The nurse's assessment reveals that a client is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate? A. Assisting client in reducing the amount of fluid build-up B. Discussing ways to increase body fat stores C. Teaching the client muscle-building exercises D. Encouraging the use of a multivitamin supplement
Teaching the client muscle-building exercises
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 The nurse should place the tape measure behind the client and measure at the umbilicus. The umbilicus should be the starting point when measuring the abdomen, especially when distention is apparent. Abdominal measurement is generally taken in the morning after voiding, not after the client has had a full meal. The ideal position to measure the abdomen is standing, not sitting. The nurse informs the client that the pen mark on the abdomen should not be washed off only if the client is being monitored on a regular basis to determine progress of treatment for abdominal distention.
After collecting subjective and objective data for the admission database, what is the nurse's next action?
Validate the client's identified problems. The nurse should develop a plan of care while adhering to the nursing process. After assessment, the client's problems should be validated. Mutual goal setting is recommended versus nurse-driven goal setting. Nursing actions should not be implemented before the plan of care is developed. The plan of care can not be completed until the client's problems are validated and mutual goals are set.
A nurse is teaching a class on diet and nutrition to a group of mothers who are breast-feeding their infants. What would the nurse tell the group is the emphasis of nutritional guidelines? A. Decreased intake of grains B. Increased intake of meats C. Variety D. Weight loss
Variety
A nurse analyzes the data obtained from the assessment of a client. The nurse has identified and clustered the abnormal data and strengths of the client. What should the nurse do next when analyzing the data?
Write down the hunches based on the cue cluster After the nurse has completed identifying the abnormal data and strengths, and has clustered the related data, the nurse should then write down hunches based on the cue cluster. Only after writing down the hunches based on the cue cluster can the nurse hypothesize and generate possible nursing diagnoses, check the defining characteristic of the cluster to choose an accurate diagnosis, and verify the diagnosis with the client and other health care professionals.
A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?
health maintenance Health maintenance includes any preventative diagnostics or health-promoting activities the client completed in the past. This is a subsection of the past history in the health assessment. The physical examination and review of systems capture the objective data that arises from the health assessment conducted by the nurse. Personal and social history capture client lifestyle factors such as family, employment, and habits.
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 Cholesterol is a fatlike substance that the liver produces. A high level of cholesterol can lead to heart attacks and strokes. However, cholesterol is important to normal bodily functions. It is necessary as a 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. Ingested fats are saturated, originating from animal sources or tropical oils and solid at room temperature, or unsaturated, originating from plant sources and soft or liquid at room temperature. Fats serve many functions in the body, but not the ones listed here. The primary functions of protein are growth, repair, and maintenance of body structures and tissue.
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? A. Extremely obese B. Underweight C. Normal weight D. Obese
Extremely obese
A woman complains of cracking fissures in the corner of her mouth (cheilosis). The nurse instructs her to consume A. Potatoes and milk B. Nuts and legumes C. Eggs and milk D. Brussel sprouts and strawberries
Eggs and milk
A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status? A. Elastic skin B. Flat, firm abdomen C. Pink mucous membranes D. Thinning, dry hair
Thinning, dry hair
A patient describes probable night blindness. Intake of what vitamin should be evaluated? A. D B. C C. A D. B
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? A. Iodine B. Vitamin B C. Thiamine D. Niacin
Vitamin B
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 The suggested implication for a red, beefy tongue is vitamin B deficiency. The finding of a red, beefy tongue in a client does not indicate thiamine deficiency, or iodine or niacin deficiency. Altered mental status is due to thiamine deficiency. A swollen neck is caused by iodine deficiency. Cracks in the corners of the mouth are because of niacin deficiency.
