PrepU ch. 5
What primary nutritional nursing consideration should be included in the physical assessment of an older adult patient?
Altered metabolism and nutrient use secondary to an acute or chronic illness
Hyperresonance is audible when which area is percussed?
Overinflated lung tissue
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?
"A trust and belief in a higher power or something you cannot see"
What is the ideal body weight (IBW) of a woman with a large frame who is 5 feet, 4 inches tall? Enter the correct number ONLY.
132
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?
23
A nurse is preparing a teaching plan based on MyPyramid recommendations to promote healthy nutrition for an adult. The nurse would recommend a daily milk intake of how many cups?
3
The nurse is discussing lifestyle changes and weight reduction with a female patient who has excess abdominal fat. What waist circumference should the patient maintain in order to remain healthy?
30 to 34 inches (76 to 86 cm)
An individual is considered obese when their BMI is what value?
30-39
When calculating ideal body weight for women, the health care professional adds how many pounds for each inch of height over 5 feet?
5
A positive nitrogen balance indicates which condition?
Tissue growth A positive nitrogen balance exists when nitrogen intake exceeds nitrogen output and indicates tissue growth. A negative nitrogen balance exists with fever, starvation, and burn injury.
A nurse is documenting a patient's chief complaint/reason for seeking care in the medical record. Which of the following would be MOST appropriate?
"My head feels like it is about to explode."
When obtaining a health history from an older adult patient, what should the nurse remember to do? (Select all that apply.)
Ask questions slowly, directly, and in a voice loud enough to be heard by those who are hearing impaired. Conduct the interview in a calm, unrushed manner using eye-to-eye contact. Clarify the frequency, severity, and history of signs and symptoms of the present illness.
Which statement made by the nurse indicates that the nurse is performing a holistic health history versus a traditional health or medical history?
"How has the stroke affected your ability to perform your daily activities?"
A graduate nurse is completing her first health history questionnaire with a client. She needs to assess the client's sexual history at the end of the interaction. Which opening remark for this topic would be most appropriate?
"Lastly, I need to ask about your sexual health and practices."
A nurse cares for an older adult client who is taking over ten different medications or supplements. What statement made by the nurse best assesses the client for medication interactions?
"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 each day?"
Which observation made by the nurse reflects the first fundamental technique used in physical examination?
"Patient appears older than stated age."
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"?
"Refusing medication can only hurt you by increasing your awareness of the pain experience."
A nurse is preparing to obtain the health history of an older adult client. Which question posed by the nurse best focuses the clinical evaluation of the older adult client?
"What interferes most in your daily activities?"
Which question asked by the nurse will provide information about a patient's lifestyle? (Select all that apply.)
"What type of exercise do you prefer?" "Do you have any food preferences?" "How many hours of sleep do you require each day?"
A waist circumference greater than which value is indicative of excess abdominal fat in men?
101.60 cm (40 in)
While undergoing a health history and physical assessment, a patient states, "I'm really afraid this pain in my belly is cancer." Which response by the nurse would be MOST appropriate?
"You seem upset about the pain. Tell me what's happening."
To calculate the ideal body weight for a woman, the nurse allows for which of the following?
100 lbs for 5 ft of height
The nurse working in a culturally diverse neighborhood knows that providing culturally sensitive materials during nutritional counseling will increase client understanding of the nutritional information. What is the best way for the nurse to prepare materials for the client in order to provide culturally appropriate teaching?
Access a government-sponsored website that provides culturally appropriate food guides.
A nurse is preparing a presentation for a group of adolescent girls about nutritional risks at this life stage. When developing this presentation, the nurse integrates knowledge about which of the following?
Adolescent girls usually do not consume enough foods that are high in iron. Adolescent girls are at a particular nutritional risk because iron, folate, and calcium intakes are below recommended levels and they are a less physically active group compared to adolescent boys.
When obtaining a health history from a patient, what should be the nurse's primary focus? (Select all that apply.)
Family history A comprehensive body systems review Current and past medical problems
Nursing students are reviewing information about the MyPyramid recommendations for food intake. The students demonstrate a need for additional review when they identify which of the following as one of the five major food groups?
Fats
A nurse is conducting a physical assessment of a patient with a cardiac murmur. Which technique would the nurse most likely use to assess the murmur?
Auscultation
A nursing student is learning to complete a focused abdominal assessment. She understands the necessity for altering the assessment skill sequence when examining this body region. Therefore, she will complete which skill after inspection?
Auscultation
A nurse determines that a patient has poor nutrition based on which assessment finding?
Beefy-red tongue Signs of poor nutrition include a beefy-red tongue, palpable thyroid gland, pale eye membranes, and flaccid, poorly toned, wasted, or underdeveloped muscles.
Which area for assessing the client profile should be addressed last?
Body Image
A nurse is obtaining family history from a patient. Which of the following would be LEAST helpful to use when documenting this information?
Checklist
A nurse is conducting a health history with a patient and has obtained the necessary biographical information. The nurse then collects data from the patient in the following categories. Place the categories in the proper sequence for data collection.
Chief complaint (reason for seeking care) Present health concern Past health history Family history Review of systems
While collecting the client profile information, the client admits to crying everyday after working 8 hours in a factory. This finding reflects what part of the profile?
Coping strategies
When the nurse is percussing for measurement of the patient's liver span, what type of response should be heard?
Dull sound
Why should the nurse to be empathetic when caring for a client?
Empathy helps the nurse become effective while remaining detached.
A community health nurse goes on a first home visit to complete a home safety assessment. Which of the following components will be part of the nurse's home safety assessment? Select all that apply.
Hard wood floors in the dining room Motion light on the porch ABC fire extinguisher in the kitchen pantry
A nurse is conducting a health assessment and interviewing a patient. Which of the following would be MOST appropriate for the nurse to do?
Listen carefully to patient responses
While assessing a client's abdomen, the nurse percusses a dull sound, not the expected tympany. Upon further reflection, the nurse realizes she has assessed what?
Liver
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 disease Albumin levels are used as measures of protein in adults. Albumin systhesis depends on normal liver function. Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss.
During a health history, a new nurse wants to make sure to include all components. Which of the following components should the nurse include? Select all that apply.
Marital status Childhood illnesses Current medications The health history is a series of questions used to provide an overview of the current health status of the client.
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.
Ratio of body weight and height Oral mucosa Thyroid gland Components of the nutritional assessment include body mass index (ratio of body weight and height), biochemical assessment, and physical examination of hair, teeth, oral cavity, thyroid gland, skeletal muscles, and abdomen.
A male client in a wheelchair comes in for his yearly physical examination. He is unable to stand. The nurse retrives the wheelchair scale to obtain an accurate weight. The nurse understands the importance of this assessment with this client. What is the nurse's reasoning for obtaining an accurate weight?
People with disabilities have an increased incidence of obesity. Many clients with disabilities report that they have not been weighed for years because they cannot stand during weighing. Alternative methods such as use of a wheelchair scale is important, because there is an increased incidence of obesity in clients with disabilities.
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
Which method of physical examination refers to the translation of physical force into sound?
Percussion
When assessing a client who has a draining wound, the nurse would be alert for which of the following nutritional consequences? Select all that apply.
Protein loss Mineral loss Electrolyte loss
During the health history, a client is making conflicting statements and has difficulty focusing. Which nursing action would be most appropriate?
Redirect the questions of concern to the client's spouse for clarification. The informant providing the health history may not always be the client.
A client with chronic obstructive pulmonary disease (COPD) visits the health care center with breathing difficulties. It is observed that during coughing bouts, the client sits up in a tripod position to breathe. During inspection, the nurse notes that the client has developed a barrel-shaped chest. Which part of the client profile relates to the client's view of himself or herself and the impact of COPD?
Self-concept
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 continues to collect information from the child's mother, knowing the informant will not always be the client.
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?
The nurse recognizes that the client's obesity may be specifically related to the endocrine disorder. The nurse performs a thorough nutritional assessment.
When examining a patient's abdomen, the nurse percusses over the stomach. Which of the following would the nurse expect to elicit?
Tympany
What does the patient have the right to know about the data collected by the nurse? (Select all that apply.)
Why the information is being obtained How the information will be used Whether the information will be held in confidence
The nurse is reviewing the laboratory test results of a patient who is suspected of having a nutritional deficiency. Which of the following would the nurse identify as helping to support this diagnosis?
low serum albumin levels
At which body mass index (BMI) value are patients considered to have increased risk for problems associated with poor nutritional status?
lower than 18.5
Two nursing students are role-playing a patient assessment situation. One of the students is acting as the nurse, and the other student is acting as the patient. The task is to focus on assessing the patient's lifestyle. Which question would be most appropriate for the student acting as the nurse to ask?
what do you usually do for fun?
