Deck 11: Nutritional Assessment

Question 1

The nurse is discussing appropriate foods with the mother of a 3-year-old child.Which of these foods are recommended?

A) Foods that the child will eat, no matter what they are
B) Foods easy to hold such as hot dogs, nuts, and grapes
C) Any foods as long as the rest of the family is eating them
D) Finger foods and nutritious snacks that can't cause choking

Answer 1

Finger foods and nutritious snacks that can't cause choking

Question 2

The nurse is performing a nutritional assessment on a 15-year-old girl,who tells the nurse that she is "so fat." Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds.The nurse's appropriate response would be:

A) "How much do you think you should weigh?"
B) "Don't worry about it; you're not that overweight."
C) "The best thing for you would be to go on a diet."
D) "I used to always think I was fat when I was your age."

Answer 2

"How much do you think you should weigh?"

Question 3

The nurse is reviewing the nutritional assessment of an 82-year-old patient.Which of these factors is most likely to affect the nutritional status of an elderly person?

A) Increase in taste and smell
B) Living alone on a fixed income
C) Change in cardiovascular status
D) Increase in gastrointestinal motility and absorption

Answer 3

Living alone on a fixed income

Question 4

The nurse is reviewing a patient's nutritional assessment.Which statement is true concerning the nutritional assessment?

A) It is only useful in patients who are overweight.
B) It identifies patients who are at risk of malnutrition.
C) This assessment can only be thoroughly done by a dietician.
D) It provides the nurse with physical findings related to all the systems.

Question 5

How should the nurse perform a triceps skinfold assessment?

A) After pinching the skin and fat, apply the calipers vertically to the fat fold.
B) Gently pinch the skin and fat on the front of the patient's arm and then apply calipers.
C) After applying the calipers, wait 3 seconds before taking a reading. Repeat the procedure three times.
D) Instruct the patient to stand with the back to the examiner and arms folded across the chest and pinch the skin on the forearm.

Question 6

The nurse is providing care for a 68-year-old woman who is complaining of constipation.What concern exists regarding her nutritional status?

A) The absorption of nutrients may be impaired.
B) The constipation may represent a food allergy.
C) She may need emergency surgery for the problem.
D) The gastrointestinal problem will increase her caloric demand.

Question 7

The nurse is seeing for the first time a patient who has no history of nutrition-related problems.The initial nutritional screening should include which activity?

A) Calorie count of nutrients
B) Anthropometric measures
C) Complete physical examination
D) Measurement of weight and weight history

Question 8

A pregnant woman is interested in breastfeeding her baby,and asks several questions about the topic.Which information is appropriate for the nurse to share with her?

A) Breastfeeding is best when also supplemented with bottle feedings.
B) Babies who are breastfed often require supplemental vitamins.
C) Breastfeeding is recommended for infants for the first 2 years of life.
D) Breast milk provides the nutrients necessary for growth as well as natural immunity.

Question 9

When considering a nutritional assessment,the nurse is aware that the most common anthropometric measurements include:

A) height and weight.
B) leg circumference.
C) biceps skinfold thickness.
D) hip and waist measurement.

Question 10

A patient is asked to indicate on a form how many times he eats a specific food.This would describe which of these methods for obtaining dietary information?

A) Food diary
B) Calorie count
C) 24-hour recall
D) Food frequency questionnaire

Question 11

The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month.Which of these problems related to his nutritional status might the nurse expect to find?

A) Obesity
B) Hypotension
C) Osteomalacia
D) Coronary artery disease

Question 12

A patient tells the nurse that his food just doesn't have any taste anymore.The nurse's best response would be:

A) "That must be really frustrating."
B) "When did you first notice this change?"
C) "My food doesn't always have a lot of taste either."
D) "Sometimes that happens but your taste will come back."

Question 13

When assessing a patient's nutritional status,the nurse recalls that the best definition of optimal nutritional status is:

A) nutrients in excess of daily body requirements.
B) sufficient nutrients to provide for the minimum body needs.
C) sufficient nutrients for daily body requirements but not for increased metabolic demands.
D) sufficient nutrients to provide for daily body requirements and for increased metabolic demands.

Question 14

During a nutritional assessment of a 22-year-old male refugee,the nurse must remember to:

A) obtain a 24-hour dietary recall.
B) clarify what is meant by the term "food."
C) provide him with a standard dietary handbook.
D) assume that his diet is consistent with other refugees from the same country.

Question 15

During a nutritional assessment,why is it important for the nurse to ask a patient what medications he or she is taking?

A) Certain drugs can affect the metabolism of nutrients.
B) The nurse needs to assess the patient for allergic reactions.
C) Medications need to be documented on the record for the physician's review.
D) Medications can affect one's memory and ability to identify food eaten in the last 24 hours.

Question 16

If a 29-year-old woman weighs 156 pounds and the nurse determines her ideal body weight to be 120 pounds,how would the nurse classify the woman's weight?

A) Obese
B) Mildly overweight
C) Suffering from malnutrition
D) Within appropriate range of ideal weight

Question 17

The nurse is providing nutrition information to the mother of a 1-year-old child.Which of these statements represents accurate information for this age group?

A) It is important to maintain adequate fat and caloric intake.
B) The recommended dietary allowances for an infant are the same as for an adolescent.
C) At this age the baby's growth is minimal so caloric requirements are decreased.
D) The baby should be placed on skim milk to decrease the risk of coronary artery disease when older.

Question 18

To assess the muscle mass and fat stores on a 40-year-old woman,the nurse would use:

A) triceps skinfold.
B) mid-thigh muscle area.
C) percent ideal body weight.
D) mid-upper arm circumference.

Question 19

The nurse recognizes that which of these persons is at greatest risk for undernutrition?

A) 5-month-old infant
B) 50-year-old woman
C) 20-year-old college student
D) 30-year-old hospital administrator

Question 20

A mother and her 13-year-old daughter express their concern related to the daughter's recent weight gain and increase in appetite.Which of these statements represents information the nurse should discuss with them?

A) It is necessary to diet and exercise at this age.
B) Snacks should be high in protein, iron, and calcium.
C) Teenagers who have a weight problem should not be allowed to snack.
D) A low-calorie diet is important to prevent the accumulation of fat.

Question 21

A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic today to find out about her laboratory results.What would be important for the nurse to include in patient teaching in relation to these tests?

A) The risks of undernutrition
B) Methods to reduce stress in her life
C) Information regarding a diet low in saturated fat
D) The fact that this condition is hereditary and there is nothing she can do to change the levels

Question 22

The nurse is concerned about the skeletal protein reserves of a patient who has been hospitalized frequently for chronic lung disease.Which of these measurements would be necessary to include in the assessment?

A) Body mass index
B) Weight and height
C) Mid-arm muscle area
D) Ideal body weight and frame size

Question 23

Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy,active 74-year-old woman?

A) Decrease the amount of carbohydrates to prevent lean muscle catabolism.
B) Increase the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis.
C) Decrease the number of calories she is eating because of the decrease in energy requirements from loss of lean body mass.
D) Increase the number of calories she is eating because of the increased energy needs of the elderly.

Question 24

A 16-year-old girl is being seen at the clinic for gastrointestinal complaints and weight loss.The nurse determines that many of her complaints may be related to erratic eating patterns,eating predominantly fast foods,and high caffeine intake.In this situation,which is most appropriate when collecting current dietary intake information?

A) Schedule a time for direct observation of the adolescent during meals.
B) Ask the patient for a 24-hour diet recall and assume this is reflective of a typical day for her.
C) Have the patient complete a food diary for 3 days, including 2 weekdays and 1 weekend day.
D) Use the food frequency questionnaire to identify the amount of intake of specific foods.

Question 25

In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia,which data would the nurse expect to find?

A) An increase in hair growth
B) Inadequate nutrient food intake
C) Weight 10% to 20% over ideal
D) Sore, inflamed buccal cavity

Question 26

When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are evaluated,which is important for the nurse to remember?

A) These measurements are no longer necessary for the elderly.
B) Derived weight measures may be difficult to interpret because of wide ranges of normal.
C) These measurements may not be accurate because of changes in skin and fat distribution.
D) Measurements may be difficult to obtain if the patient is unable to flex his elbow to at least 90 degrees.

Question 27

The nurse is performing a nutritional assessment on an 80-year-old patient.The nurse knows that physiological changes that directly affect the nutritional status of the elderly include:

A) slowed gastrointestinal motility.
B) hyperstimulation of the salivary glands.
C) an increased sensitivity to spicy and aromatic foods.
D) decreased gastrointestinal absorption causing esophageal reflux.

Question 28

After completing a diet assessment on a 30-year-old woman,the nurse suspects that she may be deficient in iron.Laboratory studies to obtain to verify this condition would be:

A) hemoglobin and hematocrit.
B) cholesterol and triglycerides.
C) urinalysis.
D) serum albumin.

Question 29

A 21-year-old woman has been on a low-protein liquid diet for the past 2 months.She has had adequate calories and appears well nourished.In further assessing her,what would the nurse expect to find?

A) Poor skin turgor
B) Decreased serum albumin
C) Increased lymphocyte count
D) Triceps skinfold less than standard

Question 30

Which of these conditions is due to an inadequate intake of both protein and calories?

A) Obesity
B) Bulimia
C) Marasmus
D) Kwashiorkor

Question 31

The nurse is reviewing laboratory studies on a patient who may have protein malnutrition.Which of these measurements is an early indicator of protein malnutrition?

A) Serum albumin
B) Serum creatinine
C) Nitrogen balance
D) Serum transferrin

Question 32

A 65-year-old man is brought to the emergency department after he was found dazed and incoherent,alone in his apartment.He has an enlarged liver and is moderately dehydrated.When evaluating his serum albumin level,the nurse must keep in mind that:

A) serum albumin levels will increase as liver function decreases.
B) serum albumin levels are a sensitive measure of early protein malnutrition.
C) low serum albumin levels may be caused by reasons other than protein-calorie malnutrition.
D) the results of the serum albumin measurement along with the patient's hemoglobin level should be considered.

Question 33

The nurse in a family practice clinic is reviewing the patients scheduled for appointments.Which of these statements is true regarding routine laboratory testing in the following individuals?

A) In pregnancy, no laboratory testing is needed unless problems with the pregnancy are suspected.
B) In the elderly, laboratory values regarding cholesterol and triglycerides are the most important because of the risk of disease.
C) Routine laboratory testing is not necessary during adolescence, except in cases of illness.
D) Laboratory tests for iron and lead levels should be assessed at 9 to 12 months.

Question 34

The nurse is measuring a patient's frame size.Which of these statements best describes the correct technique for measuring frame size?

A) With the patient standing, measure the distance from the top of the head to the back of the heel.
B) With the patient in a sitting position, measure the distance from the condyle of the humerus to the clavicle.
C) With the patient's right arm extended forward and the elbow extended, measure the distance from fingertips to the condyle of the humerus.
D) With the right arm extended forward and the elbow bent, use the calipers to measure the distance between the condyles of the humerus.

Question 35

A pregnant woman who is HIV positive is asking the nurse about breastfeeding her infant.Which of these statements is true?

A) There is not enough information to know whether it would be safe for her to breastfeed.
B) It is safe for women who are HIV positive to breastfeed.
C) Women who are HIV positive should not breastfeed because HIV can be transmitted through breast milk.
D) She can breastfeed as long as she uses pumped breast milk.

Question 36

The nurse is preparing to measure fat and lean body mass and bone mineral density.Which tool is appropriate?

A) Measuring tape
B) Skin fold calipers
C) Bioelectrical impedance analysis
D) Dual-energy x-ray absorptiometry

Question 37

In teaching a patient how to determine total body fat at home,the nurse includes instructions to obtain measurements of:

A) height and weight.
B) frame size and weight.
C) waist and hip circumferences.
D) mid-upper arm circumference and arm span.

Question 38

The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios.Which one of these patients would be at increased risk?

A) 29-year-old woman whose waist is 33 inches and whose hips are 36 inches
B) 32-year-old man whose waist is 34 inches and whose hips are 36 inches
C) 38-year-old man whose waist is 35 inches and whose hips are 38 inches
D) 46-year-old woman whose waist is 30 inches and whose hips are 38 inches

Question 39

The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair.Which of the following is true in this situation?

A) Changes in fat distribution will affect the waist-to-hip ratio.
B) Height measurements may not be accurate because of changes in bone.
C) Declining muscle mass will affect the triceps skinfold measure.
D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity.

Question 40

The mother of an 8-year-old boy is concerned about the amount of weight her son has gained.To determine whether this is a problem,the nurse will measure:

A) arm span.
B) waist-to-hip ratio.
C) skinfold thickness.
D) mid-upper arm circumference.

Question 41

A patient has been unable to eat solid food for 2 weeks,and is in the clinic today complaining of weakness,tiredness,and hair loss.The patient states that her usual weight is 175 pounds,but today she weighs 161 pounds.What is her recent weight change percentage? To calculate recent weight change percentage,use this formula:

Question 42

The nurse is assessing the body weight as a percentage of ideal body weight on an adolescent patient who was admitted for suspected anorexia nervosa.The patient's usual weight was 125 pounds,but today she weighs 98 pounds.The nurse calculates the patient's ideal body weight,and reaches which conclusion?

A) She is experiencing mild malnutrition.
B) She is experiencing moderate malnutrition.
C) She is experiencing severe malnutrition.
D) Her current weight is still within expected parameters.

Question 43

A 50-year-old patient has been brought to the emergency department after a housemate found that he could not get out of bed alone.He has lived in a group home for years,but for several months he has not participated in the activities and has stayed in his room.The nurse assesses for signs of undernutrition,and x-rays reveal that he has osteomalacia,which is a deficiency of:

A) iron.
B) riboflavin.
C) vitamin D and calcium.
D) vitamin C.

Question 44

The nurse is assessing an obese patient for signs of metabolic syndrome.This condition is diagnosed when three or more certain risk factors are present.Which of these assessment findings are risk factors for metabolic syndrome? Select all that apply.

A) Fasting plasma glucose level less than 100 mg/dL
B) Fasting plasma glucose level greater than or equal to 110 mg/dL
C) Blood pressure reading of 140/90 mm Hg
D) Blood pressure reading of 110/80 mm Hg
E) Triglyceride level of 120 mg/dL

Question 45

During an assessment of a patient who has been homeless for several years,the nurse notices that his tongue is magenta in color.This is an indication of _____ deficiency.

A) iron
B) riboflavin
C) vitamin D and calcium
D) vitamin C

Question 46

An elderly patient in a nursing home has been receiving tube feedings for several months.During an oral examination,the nurse notes that patient's gums are swollen,ulcerated,and bleeding in some areas.The nurse suspects that the patient has what condition?

A) Rickets
B) Vitamin A deficiency
C) Linoleic acid deficiency
D) Vitamin C deficiency