Chapter 11: Nutritional Assessment My Nursing Test Banks

Chapter 11: Nutritional Assessment

Jarvis: Physical Examination & Health Assessment, 7th Edition

MULTIPLE CHOICE

1. The nurse recognizes 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

ANS: A

Vulnerable groups for undernutrition are infants, children, pregnant women, recent immigrants, persons with low incomes, hospitalized people, and aging adults.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 181

MSC: Client Needs: Health Promotion and Maintenance

2. When assessing a patients nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients that:

a.

Are in excess of daily body requirements.

b.

Provide for the minimum body needs.

c.

Provide for daily body requirements but do not support increased metabolic demands.

d.

Provide for daily body requirements and support increased metabolic demands.

ANS: D

Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands resulting from growth, pregnancy, or illness.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 181

MSC: Client Needs: Health Promotion and Maintenance

3. 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.

Maintaining adequate fat and caloric intake is important for a child in this age group.

b.

The recommended dietary allowances for an infant are the same as for an adolescent.

c.

The babys growth is minimal at this age; therefore, caloric requirements are decreased.

d.

The baby should be placed on skim milk to decrease the risk of coronary artery disease when he or she grows older.

ANS: A

Because of rapid growth, especially of the brain, both infants and children younger than 2 years of age should not drink skim or low-fat milk or be placed on low-fat diets. Fats (calories and essential fatty acids) are required for proper growth and central nervous system development.

DIF: Cognitive Level: Applying (Application) REF: pp. 181-182

MSC: Client Needs: Health Promotion and Maintenance

4. 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.

ANS: D

Breastfeeding is recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development, as well as natural immunity. The other statements are not correct.

DIF: Cognitive Level: Applying (Application) REF: p. 181

MSC: Client Needs: Health Promotion and Maintenance

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

a.

Dieting and exercising are necessary 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.

ANS: B

After a period of slow growth in late childhood, adolescence is characterized by rapid physical growth and endocrine and hormonal changes. Caloric and protein requirements increase to meet this demand. Because of bone growth and increasing muscle mass (and, in girls, the onset of menarche), calcium and iron requirements also increase.

DIF: Cognitive Level: Applying (Application) REF: p. 182

MSC: Client Needs: Health Promotion and Maintenance

6. 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 (softening of the bones)

d.

Coronary artery disease

ANS: C

General undernutrition, hypertension, diarrhea, lactose intolerance, osteomalacia, scurvy, and dental caries are among the more common nutrition-related problems of new immigrants from developing countries.

DIF: Cognitive Level: Applying (Application) REF: p. 183

MSC: Client Needs: Health Promotion and Maintenance

7. For the first time, the nurse is seeing 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

ANS: D

Parameters used for nutrition screening typically include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data. The other responses reflect a more in-depth assessment rather than a screening.

DIF: Cognitive Level: Applying (Application) REF: p. 184

MSC: Client Needs: Health Promotion and Maintenance

8. A patient is asked to indicate on a form how many times he eats a specific food. This method describes which of these tools for obtaining dietary information?

a.

Food diary

b.

Calorie count

c.

24-hour recall

d.

Food-frequency questionnaire

ANS: D

With this tool, information is collected on how many times per day, week, or month the individual eats particular foods, which provides an estimate of usual intake.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 184

MSC: Client Needs: Health Promotion and Maintenance

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

a.

Absorption of nutrients may be impaired.

b.

Constipation may represent a food allergy.

c.

The patient may need emergency surgery to correct the problem.

d.

Gastrointestinal problems will increase her caloric demand.

ANS: A

Gastrointestinal symptoms such as vomiting, diarrhea, or constipation may interfere with nutrient intake or absorption. The other responses are not correct.

DIF: Cognitive Level: Applying (Application) REF: p. 182

MSC: Client Needs: Health Promotion and Maintenance

10. 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 in the record for the physicians review.

d.

Medications can affect ones memory and ability to identify food eaten in the last 24 hours.

ANS: A

Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 186

MSC: Client Needs: Health Promotion and Maintenance

11. A patient tells the nurse that his food simply does not have any taste anymore. The nurses best response would be:

a.

That must be really frustrating.

b.

When did you first notice this change?

c.

My food doesnt always have a lot of taste either.

d.

Sometimes that happens, but your taste will come back.

ANS: B

With changes in appetite, taste, smell, or chewing or swallowing, the examiner should ask about the type of change and when the change occurred. These problems interfere with adequate nutrient intake. The other responses are not correct.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 185

MSC: Client Needs: Health Promotion and Maintenance

12. 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 nurses appropriate response would be:

a.

How much do you think you should weigh?

b.

Dont worry about it; youre 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.

ANS: A

Adolescents increased body awareness and self-consciousness may cause eating disorders such as anorexia nervosa or bulimia, conditions in which the real or perceived body image does not favorably compare with an ideal image. The nurse should not belittle the adolescents feelings, provide unsolicited advice, or agree with her.

DIF: Cognitive Level: Applying (Application) REF: p. 187

MSC: Client Needs: Health Promotion and Maintenance

13. 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 also eating them

d.

Finger foods and nutritious snacks that cannot cause choking

ANS: D

Small portions, finger foods, simple meals, and nutritious snacks help improve the dietary intake of young children. Foods likely to be aspirated should be avoided (e.g., hot dogs, nuts, grapes, round candies, popcorn).

DIF: Cognitive Level: Applying (Application) REF: p. 187

MSC: Client Needs: Health Promotion and Maintenance

14. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors will most likely affect the nutritional status of an older adult?

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

ANS: B

Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that affects an older adults nutritional status.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 183

MSC: Client Needs: Health Promotion and Maintenance

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

a.

Height and weight.

b.

Leg circumference.

c.

Skinfold thickness of the biceps.

d.

Hip and waist measurements.

ANS: A

The most commonly used anthropometric measures are height, weight, triceps skinfold thickness, elbow breadth, and arm and head circumferences.

DIF: Cognitive Level: Remembering (Knowledge) REF: pp. 189-190

MSC: Client Needs: Health Promotion and Maintenance

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

a.

Obese

b.

Mildly overweight

c.

Suffering from malnutrition

d.

Within appropriate range of ideal weight

ANS: A

Obesity, as a result of caloric excess, refers to weight more than 20% above ideal body weight. For this patient, 20% of her ideal body weight would be 24 pounds, and greater than 20% of her body weight would be over 144 pounds. Therefore, having a weight of 156 pounds would be considered obese.

DIF: Cognitive Level: Applying (Application) REF: p. 190

MSC: Client Needs: Health Promotion and Maintenance

17. How should the nurse perform a triceps skinfold assessment?

a.

After pinching the skin and fat, the calipers are vertically applied to the fat fold.

b.

The skin and fat on the front of the patients arm are gently pinched, and then the calipers are applied.

c.

After applying the calipers, the nurse waits 3 seconds before taking a reading. After repeating the procedure three times, an average is recorded.

d.

The patient is instructed to stand with his or her back to the examiner and arms folded across the chest. The skin on the forearm is pinched.

ANS: C

While holding the skinfold, the lever of the calipers is released. The nurse waits 3 seconds and then takes a reading. This procedure should be repeated three times, and an average of the three skinfold measurements is then recorded.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 191

MSC: Client Needs: Health Promotion and Maintenance

18. 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.

ANS: A

Body mass index, calculated by using height and weight measurements, is a practical marker of optimal weight for height and an indicator of obesity. The other options are not correct.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 190

MSC: Client Needs: Health Promotion and Maintenance

19. 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 measures 33 inches and hips measure 36 inches

b.

32-year-old man whose waist measures 34 inches and hips measure 36 inches

c.

38-year-old man whose waist measures 35 inches and hips measure 38 inches

d.

46-year-old woman whose waist measures 30 inches and hips measure 38 inches

ANS: A

The waist-to-hip ratio assesses body fat distribution as an indicator of health risk. A waist-to-hip ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of android (upper body obesity) and increasing risk for obesity-related disease and early death. The 29-year-old woman has a waist-to-hip ratio of 0.92, which is greater than 0.8. The 32-year-old man has a waist-to-hip ratio of 0.94; the 38-year-old man has a waist-to-hip ratio of 0.92; the 46-year-old woman has a waist-to-hip ratio of 0.78.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 190

MSC: Client Needs: Health Promotion and Maintenance

20. A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic 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 should be included.

b.

Offer methods to reduce the stress in her life.

c.

Provide information regarding a diet low in saturated fat.

d.

This condition is hereditary; she can do nothing to change the levels.

ANS: C

The patient with elevated cholesterol and triglyceride levels should be taught about eating a healthy diet that limits the intake of foods high in saturated fats or trans fats. Reducing dietary fats is part of the treatment for this condition. The other responses are not pertinent to her condition.

DIF: Cognitive Level: Applying (Application) REF: p. 182

MSC: Client Needs: Health Promotion and Maintenance

21. 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.

Increase in hair growth

b.

Inadequate nutrient food intake

c.

Weight 10% to 20% over ideal

d.

Sore, inflamed buccal cavity

ANS: B

Dysphagia, or impaired swallowing, interferes with adequate nutrient intake.

DIF: Cognitive Level: Applying (Application) REF: p. 185

MSC: Client Needs: Health Promotion and Maintenance

22. A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate intake of calories and appears well nourished. After further assessment, 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

ANS: B

Kwashiorkor (protein malnutrition) is due to diets that may be high in calories but contain little or no protein (e.g., low-protein liquid diets, fad diets, and long-term use of dextrose-containing intravenous fluids). The serum albumin would be less than 3.5 g/dL.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 194

MSC: Client Needs: Health Promotion and Maintenance

23. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include:

a.

Slowed gastrointestinal motility.

b.

Hyperstimulation of the salivary glands.

c.

Increased sensitivity to spicy and aromatic foods.

d.

Decreased gastrointestinal absorption causing esophageal reflux.

ANS: A

Normal physiologic changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 182

MSC: Client Needs: Health Promotion and Maintenance

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

a.

Decreasing the amount of carbohydrates to prevent lean muscle catabolism

b.

Increasing the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis

c.

Decreasing the number of calories she is eating because of the decrease in energy requirements from the loss of lean body mass

d.

Increasing the number of calories she is eating because of the increased energy needs of the older adult

ANS: C

Important nutritional features of the older years are a decrease in energy requirements as a result of loss of lean body mass, the most metabolically active tissue, and an increase in fat mass.

DIF: Cognitive Level: Applying (Application) REF: p. 182

MSC: Client Needs: Health Promotion and Maintenance

25. 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.

Scheduling a time for direct observation of the adolescent during meals

b.

Asking the patient for a 24-hour diet recall, and assuming it to be reflective of a typical day for her

c.

Having the patient complete a food diary for 3 days, including 2 weekdays and 1 weekend day

d.

Using the food frequency questionnaire to identify the amount of intake of specific foods

ANS: C

Food diaries require the individual to write down everything consumed for a certain time period. Because of the erratic eating patterns of this individual, assessing dietary intake over a few days would produce more accurate information regarding eating patterns. Direct observation is best used with young children or older adults.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 184

MSC: Client Needs: Health Promotion and Maintenance

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

a.

Measuring tape

b.

Skinfold calipers

c.

Bioelectrical impedance analysis (BIA)

d.

Dual-energy x-ray absorptiometry (DEXA)

ANS: D

DEXA measures both bone mineral density and fat and lean body mass. BIA measures fat and lean body mass but not bone mineral density. A measuring tape measures distance or length, and skinfold calipers are used to determine skinfold thickness.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 191

MSC: Client Needs: Health Promotion and Maintenance

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

a.

Obesity

b.

Bulimia

c.

Marasmus

d.

Kwashiorkor

ANS: C

Marasmus, protein-calorie malnutrition, is due to an inadequate intake of protein and calories or prolonged starvation. Obesity is due to caloric excess; bulimia is an eating disorder. Kwashiorkor is protein malnutrition.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 194

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

28. During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color, which is an indication of a deficiency in what mineral and/or vitamin?

a.

Iron

b.

Riboflavin

c.

Vitamin D and calcium

d.

Vitamin C

ANS: B

Magenta tongue is a sign of riboflavin deficiency. In contrast, a pale tongue is probably attributable to iron deficiency. Vitamin D and calcium deficiencies cause osteomalacia in adults, and a vitamin C deficiency causes scorbutic gums.

DIF: Cognitive Level: Applying (Application) REF: p. 196

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

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

a.

Iron.

b.

Riboflavin.

c.

Vitamin D and calcium.

d.

Vitamin C.

ANS: C

Osteomalacia results from a deficiency of vitamin D and calcium in adults. Iron deficiency would result in anemia, riboflavin deficiency would result in magenta tongue, and vitamin C deficiency would result in scurvy.

DIF: Cognitive Level: Applying (Application) REF: p. 189

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

30. An older adult patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patients 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

ANS: D

Vitamin C deficiency causes swollen, ulcerated, and bleeding gums, known as scorbutic gums. Rickets is a condition related to vitamin D and calcium deficiencies in infants and children. Linoleic-acid deficiency causes eczematous skin. Vitamin A deficiency causes Bitot spots and visual problems.

DIF: Cognitive Level: Applying (Application) REF: p. 189

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

31. 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 patients usual weight was 125 pounds, but today she weighs 98 pounds. The nurse calculates the patients ideal body weight and concludes that the patient is:

a.

Experiencing mild malnutrition.

b.

Experiencing moderate malnutrition.

c.

Experiencing severe malnutrition.

d.

Still within expected parameters with her current weight.

ANS: B

By dividing her current weight by her usual weight and then multiplying by 100, a percentage of 78.4% is obtained, which means that her current weight is 78.4% of her ideal body weight. A current weight of 80% to 90% of ideal weight suggests mild malnutrition; a current weight of 70% to 80% of ideal weight suggests moderate malnutrition; a current weight of less than 70% of ideal weight suggests severe malnutrition.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 189

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE

1. The nurse is assessing a patient who is obese 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

ANS: B, C

Metabolic syndrome is diagnosed when three or more of the following risk factors are present: (1) fasting plasma glucose level greater than or equal to 100 mg/dL; (2) blood pressure greater than or equal to 130/85 mm Hg; (3) waist circumference greater than or equal to 40 inches for men and 35 inches for women; (4) high-density lipoprotein cholesterol less than 40 in men and less than 50 in women; and (5) triglyceride levels greater than or equal to 150 mg/dL (ATP III, 2001).

DIF: Cognitive Level: Applying (Application) REF: p. 197

MSC: Client Needs: Health Promotion and Maintenance

SHORT ANSWER

1. 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:

Usual weight current weight 100

usual weight

ANS:

8%

175 161 = 14 pounds

14 175 = 0.08

0.08 100 = 8%

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 189

MSC: Client Needs: Health Promotion and Maintenance

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