Deck 9: Nutritional Assessment

Question 1

The nurse has collected data on clients who have visited a health fair in the mall.Which of the following clients is most in need of a detailed nutritional assessment?
1)A 21-year-old female who has just begun college and has lost 5 pounds in the first semester
2)A 2 year old whose mother stated that he seems to be growing faster than she can buy him clothes
3)A 50-year-old male who reported that he lost 10 pounds in 6 weeks without even trying
4)A 35-year-old female who has gained 15 pounds in a year after the birth of her first child

Answer 1

3

Question 2

The nurse using the body mass index (BMI)to assess weight in a client should understand which of the following limitations of this method?
1)There is lack of correlation of the values in the BMI table with those in height-weight tables.
2)Assumption that all individuals have equal body composition at each given weight
3)BMI is difficult to accurately calculate.
4)The BMI's use to determine the risk for obesity is reduced in individuals who are on reduced calorie diets.

Answer 2

2

Question 3

The nurse is teaching a newly diagnosed diabetic about appropriate serving sizes for foods.The nurse would include which of the following estimates for a single serving of meat?
1)One cup
2)Size of a balled fist
3)Five ounces
4)Three ounces

Answer 3

4

Question 4

An 80-year-old male client is brought to the emergency room by his son with a preliminary diagnosis of dehydration.The client is agitated.When the nurse asks the client to open his mouth for an oral exam,the client yells,"You don't need to look in my mouth to see what is wrong with me!" The nurse's best rationale for looking in his mouth is:
1)That a complete physical exam must be performed.
2)To assess for poorly-fitting dentures.
3)To assess for oral lesions.
4)To assess mucous membranes.

Question 5

The nurse is interviewing a 20-year-old client who is 14 weeks pregnant and seeking prenatal care.She tells the nurse that she likes to eat ice and occasionally eats dirt.The nurse should anticipate which of the following laboratory studies to be ordered?
1)Folate level
2)Calcium levels
3)Plasma lead level
4)Hair analysis

Question 6

The nurse is admitting a 69-year-old client with a possible hip fracture.The client is overweight,so the nurse understands that there is an increased likelihood risk for which of the following?
1)Decubiti
2)Degenerative joint disease
3)Chronic pain
4)Stroke

Question 7

A 24-year-old 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.The nurse's best response would be:
1)"If you become pregnant,you will already be taking folic acid."
2)"Everyone should take vitamin supplements."
3)"Folic acid can help with your chances of getting pregnant."
4)"Most people do not get enough folic acid."

Question 8

The nurse is obtaining tricep skinfold measurements on a client.Which of the following locations would the nurse correctly use for this assessment?
1)Midpoint of the arm between the scapula and the elbow
2)Two inches and centered below the scapula
3)One inch around the umbilicus
4)Lateral aspect of thigh

Question 9

A group of college student 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?
1)BMI reports are best used for athletes who are engaging in body-building activities.
2)BMI classifications should be used only on older adults.
3)BMI classifications do not take into account racial or physical variations.
4)Nutritional status of a college student should be evaluated using skinfold measurements.

Question 10

The nurse is assessing a 12-month-old child and needs to determine length.The nurse would correctly use which of the following procedures to obtain this information?
1)Get assistance to measure the child from head to toe in prone position.
2)Wait until the child is sleeping and hold the child upright in front of a tape measure attempting for the best accuracy possible.
3)Place the child in a supine position and measure from the crown of the head to the heel while holding the legs straight.
4)Have the mother to assist the child in standing in front of a tape measure.

Question 11

The nurse has reviewed the assessment findings for a recently admitted client.The nurse notes the client's dietary intake of the vitamin B complex to be lacking.Which of the findings confirm this deficiency?
1)Loss of fat
2)Muscle wasting
3)Hyporeflexia
4)Spoon nails
5)Ataxia

Question 12

The nurse is preparing an inservice for staff on the risk factors for poor nutritional health.Which of the following would the nurse include as risk factors for overnutrition?
1)Alcohol abuse
2)Sedentary lifestyle
3)Excess intake of fat,sugar,calories,or nutrients
4)Lack of knowledge about food preparation
5)Lack of knowledge about portion sizes

Question 13

The nurse is performing a nutritional assessment and is concerned about undernutrition in a client.Which of the following conditions would cause the nurse to suspect this nutritional disorder?
1)Renal failure
2)Hypertension
3)Wound that will not heal
4)Delayed menopause

Question 14

A Bioelectrical Impedance Analysis (BIA)is being performed on a client.Which of the following is associated with this test?
1)Instruct the client to be NPO for 6 to 8 hours prior to the assessment.
2)Instruct the client to discontinue all vitamin and mineral supplementation for 24 hours prior to the assessment.
3)Instruct the client to lie in a supine position during the assessment.
4)Place electrodes on the dorsal surface of the client's foot.
5)Place electrodes on the dorsal surface of the client's hand.

Question 15

The nurse is assessing a 9-month-old girl during a well-child checkup.She is quiet and does not demonstrate much social interaction.The child appears petite and unusually small for her age.The nurse plots her height and weight on a growth chart and sees that the baby was in the 50th percentile for weight at age 6 months,and the baby is in the 5th percentile at this visit.The nurse suspects which of the following conditions in this child?
1)Congestive heart failure
2)Dehydration
3)Undernutrition
4)Hypoglycemia

Question 16

The nurse is using waist circumference to assess overnutrition in an adult female.Place a horizontal line across the figure to indicate correct placement for the measurement tape.

Question 17

The graduate nurse in orientation notices that a dietician evaluates each postoperative client's chart.They know that this is done primarily to:
1)Meet a regulatory agency requirement.
2)Determine nutritional needs.
3)Check for any cultural dietary considerations.
4)Check to see if there are any potential food-drug interactions.
5)Assess for overnutrition.

Question 18

A nurse is preparing to review an overweight client's food recall diary for the past week.Which of the following choices would be most helpful when teaching a client about recommended portion sizes?
1)Measuring cups
2)Food cups
3)Everyday items such as a deck of cards
4)Plastic containers

Question 19

The nurse is using a dietary recall tool to obtain a nutritional history on a client.The nurse must recognize the greatest limitation of using this assessment tool is which of the following?
1)Clients do not remember liquid intake from day to day.
2)It does not reflect food preferences of the client.
3)Clients do not provide reliable nutritional information.
4)It does not reflect occasional food habits.

Question 20

An overweight female client is reluctant to get on the scales at the healthcare provider's office.She verbalizes that she does not want to know how much she actually weighs.The nurse's best response would be:
1)"The doctor requires all of her clients to be weighed."
2)"This information is very important.If you step on the scales,I will just write your weight down and not say it out loud."
3)"I really do not like it either,but it has to be done."
4)"We can just use your weight from your visit last year."

Question 21

A 78-year-old female client is in the healthcare provider's office for a routine physical exam.She asks for an explanation of why skinfold measurements are not done on her anymore.The nurse's best response would be:
1)"Those tests are no longer recommended to assess BMI."
2)"As a person ages,the test is not as accurate."
3)"The BMI (body mass index)test is easier to use."
4)"A detailed dietary history will give us the information that we need."

Question 22

The school nurse is discussing dietary concerns with student members of the track team.Which of the following statements indicates the need for further instruction?
1)"There are no differences in the percentage of body fat needed by girls and boys during the teen years."
2)"The lower I can get my body fat percentage,the better."
3)"The body fat percentages needed by females is higher than that of males."
4)"There are no absolute standards for body fat percentages needed by men and women."
5)"Persons having body fat percentages greater than 20% are at an increased risk for illness."

Question 23

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 of the following factors may be associated with inaccurate reporting of dietary intake?
1)Female gender
2)Male gender
3)Higher socioeconomic levels
4)Lower educational levels

Question 24

The community health nurse is planning a program for a group of African American senior citizens.Which of the following facts should be included in the presentation?
1)The prevalence of overnutrition is greatest in African American males.
2)Hypertension is highest in the African American population.
3)Adults living at the poverty line have the greatest risk for undernutrition.
4)Iron deficiency anemia is a prevalent problem in the African American population.

Question 25

The nursing instructor is evaluating the knowledge of the student in locating the landmarks for assessing tricep skinfold measurements.Mark with and label the correct landmark for this technique.

Question 26

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?
1)"It is important for your health that you closely adhere to the recommendations of height and weight tables to avoid weight-related complications."
2)"Height and weight tables are highly subjective."
3)"Using height and weight tables can be problematic because they are often inaccurate."
4)"Height and weight tables have significant limitations for predicting weight status of an individual."

Question 27

The nurse is preparing to conduct a focused interview on a client who reports a recent weight gain.Which of the following inquiries is most appropriate?
1)"Are you eating more than you should?"
2)"Do you eat large quantities of carbohydrates?"
3)"Please tell me about what foods and beverages you have consumed for the past 24 hours."
4)"Have you noticed your energy level has decreased with your recent weight gain?

Question 28

When interviewing a 68-year-old male 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?
1)"I have been taking all of them for over 20 years now."
2)"My doctor in my old town recommended most of them."
3)"My wife also takes the same things."
4)"I know that I do not eat right all of the time,so they will keep me healthy."