Weber Health Assessment NCLEX Ch. 13: Nutritional Status
A nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present?
Chronic dieting
Which of the following are causes of weight loss? (Mark all that apply.)
Chronic renal failure Chronic infections Adrenal insufficiency
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
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.
The nurse is reviewing a client's lab data and notes the A1c is 11%. What would the nurse do next?
Give the client 10 units of regular insulin.
A nurse is working with a client who has just been given a prescription for warfarin (Coumadin). Which foods should the nurse warn this client to avoid due to its interference with the effectiveness of warfarin?
Green, leafy vegetables
Which of the following findings from a nutritional history most likely indicate the client is showing signs of an eating disorder? (Select all that apply.)
Has body mass index of 16 Discusses feeling fat in clothes
A nurse collects nutritional information on a client. Which statement by the client needs to be validated by careful objective data?
I drink two large bottles of caffeinated beverages every day.
A nurse is calculating the ideal body weight for a female client who 5 feet 2 inches tall and has a small body frame. Which of the following is this client's ideal body weight?
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 small frame, the formula would be as follows: 100 lb + 10 lb = 110 lb - 11 lb (10% of 110 lb, due to a small frame size) = 99 lb.
A nurse is calculating the ideal body weight for a male client who 6 feet 7 inches tall and has a large body frame. Which of the following is this client's ideal body weight?
Ideal body weight for a male is 106 lb for 5 ft + 6 lb for each inch over 5 ft plus or minus 10% for a small or large frame. For this male client with a large frame, the formula would be as follows: 106 lb + 114 lb = 220 lb + 22 lb (10% of 220 lb, due to a large frame size) = 242 lb.
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
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.
Malnutrition can be too much or too little nutrition. What can malnutrition do in the human body?
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.
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
Which statement about overnutrition should a nurse keep in mind when evaluating a client's nutritional status?
Muscle, bone, fat, and fluid can account for excessive weight
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
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
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.
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
An older male with a history of consuming an increased amount of processed foods since the death of his wife is complaining of heart palpitations. Which lab result is priority for the nurse to assess?
Potassium level
A nurse obtains a height measurement on an elderly client and notes that the height has decreased from 5 years ago. What is an appropriate action by the nurse?
Record this measurement in the client chart and alert the health care provider
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
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
The nurse in a bariatric clinic is providing education to a patient who wishes to lose weight. The nurse informs the patient that she has a Body Mass Indicator of 45. What does this indicate?
The patient is extremely obese
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
When would a nurse obtain a mid-arm circumference measurement?
To provide percentage of body fat and muscle tissue.
The nurse might expect the patient admitted with dehydration to have tachycardia.
True
A nurse begins a comprehensive physical examination on a client and notes that the client has a large amount of adipose tissue around the waistline. The nurse recognizes that this client should be assessed for an increased risk of which diseases? Select all that apply.
Type II diabetes mellitus Hypertension Stroke
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?
Variety
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
During a physical assessment, a client reports he has had an inflamed sore on his arm for 2 weeks with no signs of healing. The nurse notes the client also has bleeding gums. What do these findings suggest regarding the client's nutritional status?
Vitamin C deficiency
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
Which measurement should the nurse add to the body mass index to increase the predictive ability for the client?
Waist circumference
What is the most common measurement used to determine abdominal visceral fat?
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
While conducting a physical examination, the nurse notices the client's mucous membranes are pale in color. Which nutritional deficiency is most likely for this client?
anemia
A nurse assesses a 4-year-old boy who experiences gas, a stomachache, and diarrhea after consuming lactose products. The nurse recognizes this data as what type of biological variation?
biochemical
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?
bleeding gums
The nurse should perform which priority assessment on a client with a history of a high hydrogenated fat intake?
cardiac
The nurse is caring for an adult female client whose BMI is 38.7. The nurse should instruct the client that she is at greater risk for
heart attack.
Which factors should the nurse consider when counseling a client who is having difficulty gaining weight? Select all that apply.
location of grocery stores in the client's area access to financial resources presence of food allergies mood dysregulation
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?
obese
A client has a body mass index of 26.5. What teaching would be indicated for this client?
reduce caloric intake by 250-500 calories each day
The nurse is preparing to measure the triceps skinfold of an adult client. The nurse should
repeat the procedure three times and average the measurements.
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
The nurse assesses sunken eyes and poor skin turgor in a client. What should the nurse consider as a potential cause for these findings?
vomiting
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?"
At what percent of weight over ideal weight is a person considered obese?
20%
A nurse is measuring an adult male client's mid-arm circumference (MAC) as part of the overall assessment of the client's nutritional status. Which of the following is the standard reference for the MAC for an adult male?
29.3 cm
An individual is considered obese when his or her BMI is:
30-39
To quickly identify a client who may be at risk for nutritional problems, the nurse can use which of the following assessments?
A nutritional screening tool.
Which of the following patients will have an increased metabolic rate and require nutritional interventions?
A person with a serious infection and fever.
A nurse working at a health clinic performs nutritional assessments on a variety of clients in one day. Which of the following clients would be at increased risk for malnutrition? Select all that apply.
A single mother of three who makes $20,000 per year A 33-year-old smoker who says that food has lost its taste An elderly woman with Alzheimer's disease A 12-year-old girl with Crohn's disease
The nurse conducting a nutritional assessment should notify the healthcare provider of a possible eating disorder based on which finding?
Absence of menstrual periods
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
In which disease process should a nurse expect to see a client with the presence of pitting edema?
End stage renal disease
What is the use of dietary assessment data gathered from a client by a nurse?
Identify patient outcomes
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
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?
Poor iron absorption
You are completing a health assessment on a new patient. You note that the patient has dry, dull, brittle hair and dry, flaky skin with poor turgor. What might this indicate?
Poor nutritional status
A patient has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply.
blood pressure cholesterol activity level
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.
true
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."
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."
Which nutritional data obtained from a client needs validation by a nurse?
"My rings are not fitting on my fingers like they usually do"
A client asks a nurse how much exercise is needed to prevent weight gain. Which response by the nurse is accurate?
"Sixty minutes of exercise will help to prevent weight gain" The nurse should recommend to the client that 60 minutes a day of physical exercise may be needed to prevent weight gain. To keep the cardiovascular system healthy, about 30 minutes of physical activity should be performed every day. The exercise needs to be moderate in intensity. Over 60 minutes of physical activity a day may be needed to sustain weight loss.
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?
"This will make you urinate more often, so make sure you drink plenty of fluids."
A nurse is conducting a health history interview for an older adult. Which of the following questions or statements would be important for nutritional assessment?
"What prescribed and over-the-counter medicines do you take?"
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 female client with a diagnosis of hypothyroidism asks the nurse why she has begun to gain body weight. Which is the best explanation the nurse can provide?
"Your metabolism is slowing down."
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
To calculate the ideal body weight for a woman, the nurse allows
100 pounds for 5 feet of height.
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
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 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
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
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.
A nurse is helping an active 48-year-old male determine his dietary needs. Which of the following would be his estimated calorie needs per day?
2,800-3,000
Which of the following is the BMI that indicates the lowest risk of developing health problems?
23
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
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
A waist circumference of greater that which of the following is indicative of excess abdominal fat in men?
40
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
When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet?
5
A patient describes probable night blindness. Intake of what vitamin should be evaluated?
A
A nurse is caring for several patients in an outpatient setting. Which of the following patients is most likely to experience a weight gain?
A 33-year-old athlete on steroids
A client in a long term care facility has lost 5 lbs of body weight in the past month. Which of the following actions should the nurse take to determine the cause of the weight loss?
Analyze the client's intake record.
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?
BMI
A school nurse is assisting with taking baseline measurements of students at a middle school who are participating in a summer fitness program. Which pieces of equipment should the nurse gather specifically for taking anthropometric measurements? Select all that apply.
Balance beam scale with height attachment Metric measuring tape Marking pencil Skinfold calipers
The healthcare provider states that the client's blood count with differential demonstrates a shift to the left. The nurse expects to see which lab result when reviewing the differential?
Bands greater than 10% A differential indicates the various white blood cell types. Bands are granulocytes or immature white blood cells. An increased percentage indicates infection.
A nursing student is caring for a male patient who has been admitted in a severely malnourished state. For what signs of malnutrition would the student observe?
Bleeding of the gums
What assessment parameters are included when assessing a patient's nutritional status? (Mark all that apply.)
Body mass index Clinical examination findings Dietary data
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
