Health Assessment Chapter 13 PrepU
D. "This will make you urinate more often, so make sure you drink plenty of fluids." Diuretics are associated with reduced fluid intake; clients should thus be encouraged to maintain and monitor their daily fluid intake. Constipation, nausea, and iron-deficiency are not associated with diuretic use.
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? A. This might make you constipated at first, so try to include more fiber in your diet. B. "When you pick up your prescription at the pharmacy, it would be a good idea to buy some over-the-counter iron supplements as well." C. "Let me know if you feel nauseous after you start these pills, because it's not uncommon." D. "This will make you urinate more often, so make sure you drink plenty of fluids."
B. My Plate The U.S. Department of Agriculture's (USDA's) Choose My Plate is a tool to help individuals analyze their diet and set goals for a healthier diet. A calorie counter will not necessarily help the client select healthful foods. An 1800 calorie diet may be too much or insufficient to meet the client's nutritional needs. Healthy People 2020 does not provide direction as to how to improve nutritional status.
A client asks for help with determining the amount and type of foods to consume to improve nutritional intake. What should the nurse recommend that this client use? A. Healthy People 2020 B. My Plate C. an 1800 calorie diet D. calorie counter
D. liver dysfunction Abdominal ascites can develop as a result of starvation (low albumin levels will cause fluid shifts into interstitial spaces) and liver dysfunction (also related to low albumin levels). Yellowing of the skin is due to buildup of bilirubin in the body (jaundice) due to liver dysfunction (the liver is unable to conjugate the bilirubin and excrete it in the feces). Overeating, overhydration, and respiratory conditions do not cause abdominal ascites.
A client is admitted with difficulty breathing, abdominal distention, a 5 pound weight gain in the past week and yellowing of the skin. Which of the following underlying problems might be contributing to the client's weight gain? A. overhydration B. respiratory condition C. obesity D. liver dysfunction
C. Use the same scale to weigh the client. D. Have the client wear similar clothing every day. E. Weigh the client at the same time in the morning. If serial weights are prescribed, the client should be weighed at the same time in the morning, on the same scale, and wearing similar clothing. The client should be given the option to face away from the balance beam, for example, if the client has an eating disorder. Weighing the client after eating is not necessary, and obtaining the weight reading at varying times of the day can affect the accuracy of serial weight measurements.
A client is prescribed serial weight measurements every day. What action(s) will the nurse take when conducting these serial weights? Select all that apply. A. Encourage the client to look at the balance beam. B. Weigh the client after eating the morning or midday meal. C. Use the same scale to weigh the client. D. Have the client wear similar clothing every day. E. Weigh the client at the same time in the morning.
B. It may be immunosuppression resulting from undernourishment. Since nearly everyone has been exposed to diseases such as tuberculosis, measles, or yeast infections, an absence of reaction to intradermal injection can indicate immunosuppression resulting from malnutrition. Absence of a reaction does not indicate a sacrifice of skeletal muscle and blood proteins or unhealthy dietary habits. Specific blood tests are available to evaluate cholesterol and triglyceride levels, as well as various body proteins.
A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. What conclusion is suggested if the client has no reaction? A. It indicates high cholesterol and triglyceride levels. B. It may be immunosuppression resulting from undernourishment. C. It is indicative of unhealthy dietary habits. D. It shows a sacrifice of skeletal muscle proteins and blood proteins.
B. 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 client 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.
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 client? A. Structure eating so that no more than 500 calories are consumed each day. B. Reducing her weight by 5% can lower her risk C. Reduce daily calorie intake by 100 calories each day. D. Plan to reduce weight by 20% in 6 months.
B. "What is your height and usual weight?" C. Are any members of your family obese? D. "How do you decide your diet?" The nurse should ask the client whether there are obese members in the family. Obesity often runs in the family. In addition, families may have unhealthy eating patterns that contribute to obesity. Asking the client about the diet helps to identify chronic dieters and clients with eating disorders. Asking the clients height and weight provides a baseline for comparing the clients perception with actual and current measurements. It also indicates the clients knowledge of his or her own health status. The client should be asked about the comfort level when on the examination table or in bed at home when collecting objective data, not subjective date. The client should be asked about preferences and not asked a direct question about relishing all kinds of food, which is a leading question and provides no helpful information.
A nurse is assessing a client who is obese, gathering subjective date. Which subjective questions regarding nutritional status are appropriate for the nurse to ask this client? Select all that apply. A. "Are you comfortable in your current position?" B. "What is your height and usual weight?" C. Are any members of your family obese? D. "How do you decide your diet?" E. "Do you like eating all kinds of food?"
D. "Decrease your daily caloric intake and increase your physical activity." Obesity is defined as a BMI of 30 or greater; this places clients at high risk for chronic diseases such as diabetes, cardiovascular, and musculoskeletal problems. The nurse should educate the client on diet and exercise to lose weight (decrease food intake and increase activity). The nurse would not advise the client to increase food intake or decrease daily physical activity or to continue with the current regimen because their BMI is 30.
A nurse is providing nutritional teaching for a client with a body mass index (BMI) of 30. What teaching should the nurse provide? A. "Increase your daily physical activity and calories by 500 a day." B. "Decrease your daily physical activity and increase your caloric intake." C. "Continue with your current food intake and exercise regimen." D. "Decrease your daily caloric intake and increase your physical activity."
A. Variety Emphasis of nutritional guidelines is on variety; increased intake of vegetables, fruits, lentils, and grains, particularly from plant sources; and meeting individual nutritional needs while avoiding either deficiencies or excesses in nutrient intake.
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. Weight loss C. Variety D. Increased intake of meats
C. 206.4 lb Generally, a person who is 10% over ideal body weight (IBW) is considered overweight, whereas one who is 20% over IBW is considered obese. Twenty percent of 172 would be 34.4; 34.4 + 172 = 206.4.
A nurse is working with a client whose ideal body weight is 172 lb. At what weight would this client first be considered obese? A. 189.2 lb B. 240.8 lb C. 206.4 lb D. 223.6 lb
B. 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.
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. Provide support or hold the client to record the height B. Measure the arm span to estimate height C. Obtain this information subjectively from the client D. Use a standard chart for height by age and gender
D. 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.
A nursing student is caring for a male client who has been admitted in a severely malnourished state. For what signs of malnutrition would the student observe? A. Liver pain B. Increased scrotum size C. Cranium that appears larger in proportion to body D. Bleeding of the gums
A. Poor iron absorption Low hemoglobin and hematocrit counts may indicate poor iron intake or absorption. Other factors such as bleeding, fluid excess, or low intake of vitamin B12 and folate may also decrease these values.
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? A. Poor iron absorption B. High-folate level C. Decreased calcium level D. Fluid deficit
D. 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.
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? A. dry flaky skin B. bone pain C. paresthesias D. bleeding gums
B. End stage renal disease Pitting edema is a sign of fluid retention ; is commonly seen in client with cardiac or renal disease because the circulatory system cannot handle the excess fluid; it leaks into the tissues. Pitting edema is most commonly seen in the lower extremities. Colon cancer, diabetes mellitus, and liver disease do not normally cause pitting edema because these disease processes do not involve fluid retention.
In which disease process should a nurse expect to see a client with the presence of pitting edema? A. Colon cancer B. End stage renal disease C. Diabetes mellitus D. Liver disease
B. The client is extremely obese Body Mass Indicator is a ratio based on body weight and height. A BMI of 25 to 29 is considered overweight, a BMI of 30 to 39 obese and a BMI greater than 40 extremely obese. Options A,C and D are incorrect, they are not in the appropriate range on the BMI scale.
The nurse in a bariatric clinic is providing education to a client who wishes to lose weight. The nurse informs the client that she has a Body Mass Indicator of 45. What does this indicate? A. The client is a normal weight B. The client is extremely obese C. The client is overweight D. The client is mildly obese
A. Assess the client's dentures for proper fit. Poor-fitting dentures can detract from the enjoyment of meals, and unless the situation is remedied there can be a further decrease in weight. Losing weight doesn't automatically cause an older adult to be at risk for falls. If the client is having difficulty with maintaining proper fluid status, they will be at risk for falls. Older adults need to consume diets high in protein. Mealtimes should be as enjoyable as possible.
The nurse in a long-term care facility is caring for an older adult client who had a 7% weight loss over a two-year period. Which is an expected intervention based on the information? A. Assess the client's dentures for proper fit. B. Place the client on fall risk precautions. C. Teach the client to choose food low in protein. D. Ask the client to eat in their room to avoid distractions at mealtime.
B. "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 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? A. "Waist circumference can vary over the course of the day." B. "Let's discuss your risk factors for heart disease." C. "We should review the amount of protein in your diet." D. "You probably have a vitamin deficiency."
A. Cardiac The cardiac assessment is of priority concern for this client. Foods made with hydrogenated fats are particularly harmful to the diet because they are the largest contributors of trans fats. Empirical evidence suggests that trans fats are as damaging to the heart and blood vessels as saturated fats (Mente de Koning, Shannon, and Anand, 2009).
The nurse should perform which priority assessment on a client with a history of a high hydrogenated fat intake? A. Cardiac B. Musculoskeletal C. Respiratory D. Skin
A. 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.
To calculate the ideal body weight for a woman, the nurse allows A. 100 pounds for 5 feet of height. B. 6 pounds for each additional inch over 5 feet. C. 106 pounds for 5 feet of height. D. 80 pounds for 5 feet of height.
C. magenta tongue
When evaluating data on a client with an eating disorder, the nurse would expect to find A. hypertension B. yellow sclerae C. magenta tongue D. bradycardia
C. A person with a serious infection and fever. Factors that increase metabolic rate include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of some hormones. Aging, prolonged fasting, and sleep decrease metabolic rate.
Which of the following clients will have an increased metabolic rate and require nutritional interventions? A. A healthy young adult who works in an office. B. A retired person living in a temperate climate. C. A person with a serious infection and fever. D. An older, sedentary adult with painful joints.
C. activity level D. blood pressure E. cholesterol
A client has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply. A. temperature B. medications C. activity level D. blood pressure E. cholesterol
A. 24.4 The BMI is calculated by dividing weight in pounds by height in inches squared and then multiplying by 703. For a client who is 5 feet 11 inches tall and 175 pounds, the calculation is as follows: 5 feet 11 inches equals (5 × 12) + 11 = 71 inches. (175 / 712) × 703 = (175 / 5041) × 703 = 24.4
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. 24.4 B. 34.4 C. 18.9 D. 29.9
D. 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 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. 52 D. 46
D. I drink two large bottles of caffeinated beverages every day. Excessive intake of diuretic fluids, such as coffee or other caffeinated beverages, can lead to dehydration. The nurse needs to validate how much a large bottle contains and collect objective data to assess for findings of dehydration. Packing a lunch to control calorie intake and exercising 30 minutes a day is healthy. Eating small amounts of food more frequently is also a helpful way to control weight.
A nurse collects nutritional information on a client. Which statement by the client needs to be validated by careful objective data? A. "I eat small amounts of food 5 to 6 times a day." B. "Packing a lunch helps me to control my calorie intake." C. "I exercise about 30 minutes a day to control my weight." D. I drink two large bottles of caffeinated beverages every day.
D. Class I obesity A body mass index (BMI) of 31.6 kg/m2 falls within the category of obesity, specifically class I obesity. A BMI that ranges from 25.0 to 29.9 falls within the category of overweight. A BMI ranging from 35.0 to 39.9 falls within the category of class II obesity. A BMI equal to or greater than 40 indicates extreme or class III obesity.
A nurse determines that a client has a body mass index (BMI) of 31.6 kg/m2. The nurse interprets this finding to suggest which of the following? A. Class II obesity B. Overweight C. Class III obesity D. Class I obesity
C. A 33-year-old athlete on steroids A client taking steroids may gain weight.
A nurse is caring for several clients in an outpatient setting. Which of the following clients is most likely to experience a weight gain? A. A 27-year-old woman with pneumonia B. A 42-year-old client with irritable bowel syndrome C. A 33-year-old athlete on steroids D. A 39-year-old who has been in remission from cancer for 4 years
A. 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.
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? A. Cholesterol B. Unsaturated fat C. Protein D. Saturated fat
A. Cancer A population that is particularly at risk for developing malnutrition is the client with cancer. Wasting syndrome, known as cachexia or cancerous or malignant cachexia, can develop. This type of malnutrition is characterized by an abnormal metabolic rate, anorexia, muscle wasting, severe weight loss, and general decline in condition. Cachexia is not associated with cardiovascular disease, diabetes, or osteoporosis.
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? A. Cancer B. Osteoporosis C. Cardiovascular disease D. Diabetes
A. 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.
A nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present? A. Chronic dieting B. Excessive exercise C. Single parenthood D. Diabetes mellitus
D. The client weighs 20% more than ideal body weight (IBW). When intake of nutrients exceeds a person's metabolic needs, overnutrition occurs, which is considered another form of malnutrition. If a person exceeds 10% over ideal body weight (IBW) they are considered to be overweight; whereas someone who exceeds 20% over IBW is considered to be obese. Obesity may lead to type 2 diabetes and other chronic diseases. The fact that the client gained 10 lbs. in the last month does not necessarily mean the client is obese because the client could have been underweight.
A nurse reviews the findings of an admission assessment. The nurse will determine the client meets the criteria of obesity based on which of the following findings? A. The client states they have gained 10 lbs. in the last month. B. The client is 5% over ideal body weight (IBW). C. The client has a diagnosis of type 2 diabetes. D. The client weighs 20% more than ideal body weight (IBW).
D. 1.0 liters A change of 2.2 lb (1 Kg) of weight is equal to a gain of 1 liter of fluid.
A nurse weighs a client today and finds that the client's weight has increased 2.2 lbs from the previous day. The nurse interprets this finding as suggesting a fluid gain of which amount? A. 0.5 liters B. 2.0 liters C. 1.5 liters D. 1.0 liters
C. 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.
A waist circumference of greater that which of the following is indicative of excess abdominal fat in men? A. 35 B. 25 C. 40 D. 30
D. Nails are strong Nails are strong; is the documentation that represents a normal finding. Clothing that is too large might indicate weight loss. Thin, oily hair is not generally a normal finding, nor are white patches on the oral mucosa.
After assessing a new client, the nurse documents findings in the medical record. What is the best example of documenting normal findings? A. Clothing appears too large B. Hair is thin and appears oily C. Oral mucosa is pink with white patches D. Nails are strong
B. 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.
An individual is considered obese when his or her BMI is: A. Greater than 40 B. 30-39 C. 25-29 D. Less than 24
B. 20% Obesity is defined as body weight 20% or more above ideal weight.
At what percent of weight over ideal weight is a person considered obese? A. 100% B. 20% C. 40% D. 60%
B. 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.
Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease? A. Clients with a BMI of 23. B. Females with 88.9 cm (35 in) or greater waist circumference. C. Males with 88.9 cm (35 in) or greater waist circumference. D. Clients with a BMI of 20.
D. 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 clients to bed. Therefore options A, B and C are incorrect.
Malnutrition can be too much or too little nutrition. What can malnutrition do in the human body? A. Decreased risk of disease complications B. Decrease wound healing time C. Contribute to shorter hospital stays D. Prolong confinement to bed
True If a scale is available, the nurse should instruct the client to stand shoeless on the scale with heels together and back straight, looking straight ahead. The nurses then should use the L-shaped measuring attachment on the scale to measure height.
TRUE or FALSE When beginning a height measurement on a 14-year-old, the nurse should instruct the client to stand on the scale with heels together.
A. Health-seeking behaviors related to desire and request to alter amount of food intake Health promotion diagnoses reflect a desire for a higher degree of health. Health-seeking behaviors are an example. Imbalanced nutrition and ineffective thermoregulation reflect actual nursing diagnoses.
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 nursing diagnosis would best for this client? A. Health-seeking behaviors related to desire and request to alter amount of food intake B. Imbalanced nutrition: less than body requirements related to inadequate caloric intake C. Ineffective thermoregulation related to decreased adaptability to cold secondary to decreased subcutaneous tissue D. Imbalanced nutrition: more than body requirements related to excessive caloric intake
A. glycogen B. fiber Simple carbohydrates include glucose, dextrose, fructose, galactose, sucrose, maltose, and lactose. Examples of simple carbohydrates include candy, sugary drinks, syrups, and table sugar. Complex carbohydrates include starch, glycogen, and fiber. Examples of complex carbohydrates include whole grains, legumes, vegetables, and fruits.
The nurse instructor is helping student nurses to better understand the body's main source of energy, carbohydrates. The nurse instructor determines that further education is needed when a student lists which of the following as simple carbohydrate(s)? A. glycogen B. fiber C. dextrose D. glucose E. fructose
D. Meat and dairy products. The nurse should place emphasis on protein sources, such as milk and meat, to boost tissue building for this client.
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? A. Leafy green vegetables and fruit. B. Citrus fruits and mixed vegetables. C. Whole grains and nut butter. D. Meat and dairy products.
C. Body mass index (BMI). As with BMI, waist circumference guidelines may not be as accurate with adult clients who are shorter than five feet in height.
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? A. Mid-arm circumference. B. Triceps skinfold measurements. C. Body mass index (BMI). D. Ideal weight.
B. Dietary data D. Clinical examination findings E. Body mass index The sequence of assessment of parameters may vary, but evaluation of nutritional status includes one or more of the following methods: measurement of body mass index and waist circumference, biochemical measurements, clinical examination findings, and dietary data. Ethnic mores and wrist circumference are not assessment parameters for nutritional status.
What assessment parameters are included when assessing a client's nutritional status? (Mark all that apply.) A. Wrist circumference B. Dietary data C. Ethnic mores D. Clinical examination findings E. Body mass index
B. Overhydration Edema may be secondary to a protein deficiency or overhydration in a client with a weak heart.
What can cause edema in a client with a weak heart? A. Hyperproteinemia B. Overhydration C. Dehydration D. Hyponatremia
A. Waist circumference. Waist circumference is the most common measurement used to determine the extent of abdominal visceral fat in relation to body fat.
What is the most common measurement used to determine abdominal visceral fat? A. Waist circumference. B. Subcutaneous fat determination. C. Triceps skinfold thickness. D. Body mass index.
B. 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.
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. Thiamine B. Vitamin B C. Niacin D. Iodine
D. To provide percentage of body fat and muscle tissue. Measure mid-arm circumference (MAC) evaluates skeletal muscle mass and fat stores.
When would a nurse obtain a mid-arm circumference measurement? A. To assist in determining body mass index. B. To screen for nutritional excess or deficits. C. To confirm an abnormal albumin level. D. To provide percentage of body fat and muscle tissue.
D. 23 A BMI in the normal range (18.5;24.9) carries the lowest risk of developing health problems. Being either underweight or overweight increases a person's risk of developing health problems.
Which of the following is the BMI that indicates the lowest risk of developing health problems? A. 18 B. 28 C. 33 D. 23
B. Obese A body mass index of 31 is considered clinically obese. People who have a BMI lower than 18.5 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Those who have a BMI of 25 to 29 are considered overweight; those with a BMI of 30 to 39, obese; and those with a BMI greater than 40, extremely obese.
You are the clinic nurse assessing a new client that has come in to see a physician. The assessment data that you collect reveals that the client 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. Underweight B. Obese C. Average weight D. Overweight
