Deck 12: Nutritional Assessment

Question 1

The nurse is preparing an in-service for staff on the risk factors for poor nutritional health. Which risk factors for overnutrition will the nurse include?

A) Alcohol abuse.
B) Sedentary lifestyle.
C) Excess intake of fat, sugar, calories, or nutrients.
D) Lack of knowledge about food preparation.
E) Lack of knowledge about portion sizes.

Answer 1

Sedentary lifestyle.
Excess intake of fat, sugar, calories, or nutrients.
Lack of knowledge about food preparation.
Lack of knowledge about portion sizes.

Question 2

A nurse is preparing to review an overweight client's food recall diary for the past week. Which choice would be most helpful when teaching a client about recommended portion sizes?

A) Measuring cups.
B) Food cups.
C) Everyday items such as a deck of cards.
D) Plastic containers.

Answer 2

Everyday items such as a deck of cards.

Question 3

The nurse is obtaining tricep skinfold measurements on a client. Which locations would the nurse correctly use for this assessment?

A) Midpoint of the arm between the scapula and the elbow.
B) Two inches and centered below the scapula.
C) One inch around the umbilicus.
D) Lateral aspect of thigh.

Answer 3

Midpoint of the arm between the scapula and the elbow.

Question 4

The graduate nurse in orientation notices that a dietician evaluates each postoperative client's chart. Which are primary reasons for this action?

A) Meet a regulatory agency requirement.
B) Determine nutritional needs.
C) Check for any cultural dietary considerations.
D) Check to see if there are any potential food-drug interactions.
E) Assess for overnutrition.

Question 5

The nurse is teaching a newly diagnosed diabetic about appropriate serving sizes for foods. Which estimate for a single serving of meat will the nurse include in the teaching session?

A) One cup.
B) Size of a balled fist.
C) Five ounces.
D) Three ounces.

Question 6

The nurse is assessing an infant and needs to determine length. Which procedure is appropriate for the nurse to use to measure length?

A) Get assistance to measure the child from head to toe in prone position.
B) Wait until the child is sleeping and hold the child upright in front of a tape measure attempting for the best accuracy possible.
C) Place the child in a supine position and measure from the crown of the head to the heel while holding the legs straight.
D) Have the mother to assist the child in standing in front of a tape measure.

Question 7

The nurse is admitting an overweight older adult client to the medical-surgical unit with a possible hip fracture. Based on this assessment data, which diagnosis does the nurse anticipate for this client?

A) Decubiti.
B) Degenerative joint disease.
C) Chronic pain.
D) Stroke.

Question 8

The nurse conducts a nutritional assessment and concludes that the client is experiencing undernutrition. Which condition would cause the nurse to suspect this nutritional disorder?

A) Renal failure.
B) Hypertension.
C) Wound that will not heal.
D) Delayed menopause.

Question 9

The nurse is calculating the percent weight change of an adult client, weighing 156 pounds 1 month ago, and 140 pounds on current examination. Which percent of weight change will the nurse document for the client in the medical record?

A) 5%.
B) 10%.
C) 12%.
D) 14.3%.

Question 10

An older adult client is brought to the emergency department by an adult child with a preliminary diagnosis of dehydration. The client is agitated and when asked by the nurse to open the mouth the client yells, "You don't need to look in my mouth to see what is wrong with me!" Which rationale for conducting a mouth assessment is the most accurate?

A) That a complete physical exam must be performed.
B) To assess for poorly fitting dentures.
C) To assess for oral lesions.
D) To assess mucous membranes.

Question 11

The nurse is performing anthropometric measurements on a client in the clinic setting. Which definition of this term would the nurse use when explaining this measurement to the client?

A) The assessment is obtained by subtracting the height in centimeters from the weight in pounds and multiplying by two.
B) The assessment includes any scientific measurement of the body for nutritional analysis.
C) The measurements include the use of growth chart evaluations to plot height and weight.
D) The measurement estimates skinfold thicknesses.

Question 12

The nurse is calculating the body mass index (BMI) to assess a client's weight. Which is a limitation to using this tool?

A) There is lack of correlation of the values in the BMI table with those in height-weight tables.
B) Assumption that all individuals have equal body composition at each given weight.
C) BMI is difficult to accurately calculate.
D) The BMI's use to determine the risk for obesity is reduced in individuals who are on reduced calorie diets.

Question 13

The nurse has calculated the BMI (body mass index) of an adult client who weighs 169 pounds and is 6 feet in height, and has obtained a result of 23. Which interpretation of this data by the nurse is the most appropriate?

A) Mild malnutrition.
B) Normal.
C) Overweight.
D) Obese class 1.

Question 14

A young adult client visits the healthcare provider office for a routine yearly gynecological exam. The nurse is providing education to the client. The client asks for an explanation of why the nurse recommended that she take a multivitamin that contains folic acid. Which response by the nurse is the most appropriate?

A) "If you become pregnant, you will already be taking folic acid."
B) "Everyone should take vitamin supplements."
C) "Folic acid can help with your chances of getting pregnant."
D) "Most people do not get enough folic acid."

Question 15

The nurse admits a client to the medical-surgical unit. After completing a nutritional assessment, the nurse notes that the client has a deficiency of protein and overall caloric intake. Which finding supports this conclusion by the nurse?

A) Loss of fat.
B) Muscle wasting.
C) Hyporeflexia.
D) Spoon nails.
E) Ataxia.

Question 16

The nurse is assessing a 9-month-old infant during a well-child checkup. The infant is quiet, does not demonstrate much social interaction, and is small for age. The nurse plots the infant's height and weight on a growth chart and sees that the baby was in the 50th percentile for weight at age 6 months, and is now in the 5th percentile. Which condition does the nurse suspect?

A) Congestive heart failure.
B) Dehydration.
C) Undernutrition.
D) Hypoglycemia.

Question 17

The nurse is interviewing a young adult client who is 14 weeks pregnant and seeking prenatal care. The client tells the nurse that she likes to eat ice and occasionally eats dirt. Based on this data, which laboratory study does the nurse anticipate will be prescribed by the healthcare provider?

A) Folate level.
B) Calcium levels.
C) Plasma lead level.
D) Hair analysis.

Question 18

The nurse is using waist circumference to assess overnutrition in an adult female. Which is the correct placement for the measurement tape?

A) A.
B) B.
C) C.
D) D.

Question 19

A Bioelectrical Impedance Analysis (BIA) is being performed on a client. Which interventions will the nurse implement for this client?

A) Instruct the client to be NPO for 6 to 8 hours prior to the assessment.
B) Instruct the client to discontinue all vitamin and mineral supplementation for 24 hours prior to the assessment.
C) Instruct the client to lie in a supine position during the assessment.
D) Place electrodes on the dorsal surface of the client's foot.
E) Place electrodes on the dorsal surface of the client's hand.

Question 20

The nurse is using a dietary recall tool to obtain a nutritional history on a client. Which is the greatest limitation when using this tool to assess the client?

A) Clients do not remember liquid intake from day to day.
B) It does not reflect food preferences of the client.
C) Clients do not provide reliable nutritional information.
D) It does not reflect occasional food habits.

Question 21

When interviewing an older adult client, the nurse discovers a list of 23 herbal and vitamin supplements that are being consumed by the client each day. Which response by the client indicates the need for further nutritional teaching by the nurse at this visit?

A) "I have been taking all of them for over 20 years now."
B) "My doctor in my old town recommended most of them."
C) "My wife also takes the same things."
D) "I know that I do not eat right all of the time, so they will keep me healthy."

Question 22

A group of college athletes from the volleyball team have reported concerns about the reports regarding their weight and nutritional status. The reports were based on BMI (body mass index) values. The team's healthcare provider that collected the data and sent the reports decided to change their recommendations based on which explanation?

A) BMI reports are best used for athletes who are engaging in bodybuilding activities.
B) BMI classifications should be used only on older adults.
C) BMI classifications do not take into account racial or physical variations.
D) Nutritional status of a college student should be evaluated using skinfold measurements.

Question 23

The community health nurse is planning a program for a group of African American older adult clients. Which fact should the nurse include in the presentation?

A) The prevalence of overnutrition is greatest in African American males.
B) Hypertension is highest in the African American population.
C) Adults living at the poverty line have the greatest risk for undernutrition.
D) Iron deficiency anemia is a prevalent problem in the African American population.

Question 24

The nurse is preparing to assess a client's tricep skinfold measurement. Which location is appropriate for the nurse to use during this assessment?

A) A.
B) B.
C) C.
D) D.

Question 25

The nurse is collecting nutritional intake information from a client. The nurse does not feel the client is being forthcoming and honest with the intake self-reports. Which factor may be associated with inaccurate reporting of dietary intake?

A) Female gender.
B) Male gender.
C) Higher socioeconomic levels.
D) Lower educational levels.

Question 26

The nurse is preparing to conduct a focused interview on a client who reports a recent weight gain. Which inquiry by the nurse is the most appropriate for this client?

A) "Are you eating more than you should?"
B) "Do you eat large quantities of carbohydrates?"
C) "Please tell me about what foods and beverages you have consumed for the past 24 hours."
D) "Have you noticed your energy level has decreased with your recent weight gain?

Question 27

The nurse collects data on clients who have visited a health fair in the mall. Which client would benefit the most from a detailed nutritional assessment?

A) A 21-year-old female who has just begun college and has lost 5 pounds in the first semester.
B) A 2-year-old whose mother stated that he seems to be growing faster than she can buy him clothes.
C) A 50-year-old male who reported that he lost 10 pounds in 6 weeks without even trying.
D) A 35-year-old female who has gained 15 pounds in a year after the birth of her first child.

Question 28

An overweight client is reluctant to get on the scales at the healthcare provider's office. The client verbalizes that not wanting to know the current weight. Which response by the nurse is the most appropriate?

A) "The doctor requires all of her clients to be weighed."
B) "This information is very important. If you step on the scales, I will just write your weight down and not say it out loud."
C) "I really do not like it either, but it has to be done."
D) "We can just use your weight from your visit last year."

Question 29

The school nurse is discussing dietary concerns with student members of the track team. Which student statements indicate the need for further instruction?

A) "There are no differences in the percentage of body fat needed by girls and boys during the teen years."
B) "The lower I can get my body fat percentage, the better."
C) "The body fat percentage needed by females is higher than that of males."
D) "There are no absolute standards for body fat percentages needed by men and women."
E) "Persons having body fat percentages greater than 20% are at an increased risk for illness."

Question 30

An older adult client is in the healthcare provider's office for a routine physical exam. The client asks for an explanation of why skinfold measurements are not done as part of her assessment anymore. Which response by the nurse is the most appropriate?

A) "Those tests are no longer recommended to assess BMI."
B) "As a person ages, the test is not as accurate."
C) "The BMI (body mass index) test is easier to use."
D) "A detailed dietary history will give us the information that we need."

Question 31

The nurse is collecting data from a client at the ambulatory care clinic. During the meeting, the client asks the nurse about using height and weight tables to determine his ideal weight. What response by the nurse is most appropriate?

A) "It is important for you to adhere to the recommendations of height and weight tables to avoid weight-related complications."
B) "Height and weight tables are highly subjective."
C) "Using height and weight tables can be problematic because they are often inaccurate."
D) "Height and weight tables have significant limitations for predicting weight status of an individual."