Chapter 9 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 9

Question 1

Type: MCSA

The nurse has calculated the BMI (body mass index) of a 54-year-old client who weighs 169 pounds and is 6 feet in height, and has obtained a result of 23. The nurse would correctly interpret this results as which of the following?

1. Mild malnutrition

2. Normal

3. Overweight

4. Obese class 1

Correct Answer: 2

Rationale 1: Mild malnutrition is considered a BMI of 1718.49.

Rationale 2: Normal BMI ranges between 18.5 and 24.9.

Rationale 3: Overweight BMIs are between 25 and 29.9.

Rationale 4: Obese class 1 BMIs are between 30 and 34.9.

Global Rationale: Adult BMI classification places a result of 23 within the range of normal, which includes BMIs between 18.5 and 24.9. Mild malnutrition is considered a BMI of 1718.49. Overweight BMIs are between 25 and 29.9. Obese class 1 BMIs are 3034.9.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.1: Define nutritional health.

Question 2

Type: MCSA

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.

Correct Answer: 4

Rationale 1: The diet recall does not reflect all flood and liquids taken in during the previous 24 hours or longer.

Rationale 2: A 24-hour dietary recall does not need to reflect food preferences of the client to provide the needed information.

Rationale 3: Although a 24-hour dietary recall is not the most reliable method to obtain information, it is considered somewhat reliable.

Rationale 4: The food habits that are employed occasionally are not the focus of a 24-hour dietary recall. It is used to determine recent intake.

Global Rationale: One limitation of the 24-hour dietary recall is that it does not, or may not, reflect food habits that occur occasionally but not on the day recalled. It is not the most reliable way of obtaining information since it does rely on the clients memory; however, it is considered somewhat reliable and a useful tool for nutritional assessment. It does not need to reflect food preferences. The diet recall does reflect all food and liquids taken in during the previous 24 hours, or longer period, if asked.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.6: Describe existing validated nutritional assessment tools.

Question 3

Type: MCSA

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

Correct Answer: 1

Rationale 1: Tricep skinfold measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow.

Rationale 2: Tricep skinfold measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not 2 inches and centered below the scapula.

Rationale 3: Tricep skinfold measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not at the umbilical region.

Rationale 4: Tricep skinfold measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not in the lateral aspect of thigh.

Global Rationale: Tricep skinfold measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow. The remaining answers are not tricep skinfolds.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.4: Identify physical and laboratory parameters utilized in a nutrition assessment

Question 4

Type: MCSA

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 BMIs use to determine the risk for obesity is reduced in individuals who are on reduced calorie diets.

Correct Answer: 2

Rationale 1: There is lack of correlation of the values in the BMI table with those in height-weight tables. A clinical limitation of body mass index is the assumption that all individuals have equal body composition at each given weight. This has not been found to be true.

Rationale 2: Assumption that all individuals have equal body composition at each given weight. A clinical limitation of body mass index is the assumption that all individuals have equal body composition at each given weight. This has not been found to be true. The amount of muscle mass, body fat, and bone mineral content varies according to high level of fitness, race, and ethnic differences.

Rationale 3: BMI is difficult to accurately calculate. BMI is easily calculated using the standard formula and has a relationship with height and weight.

Rationale 4: The BMIs use to determine the risk for obesity is reduced in individuals who are on reduced calorie diets. The BMI is not used to determine the risk for obesity. The use of the tool is not limited by an individuals current caloric intake.

Global Rationale: A clinical limitation of body mass index is the assumption that all individuals have equal body composition at each given weight. This has not been found to be true. The amount of muscle mass, body fat, and bone mineral content varies according to high level of fitness, race, and ethnic differences. BMI is easily calculated using the standard formula and has a relationship with height and weight. The BMI is not used to determine the risk for obesity. The use of the tool is not limited by an individuals current caloric intake.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.4: Identify physical and laboratory parameters utilized in a nutrition assessment.

Question 5

Type: MCSA

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

Correct Answer: 3

Rationale 1: Renal failure. There are many causes of kidney failure which are not related to nutrition.

Rationale 2: Hypertension. Hypertension often accompanies overnutrition.

Rationale 3: Wound that will not heal. Undernutrition can lead to delayed growth, compromised immune status, poor wound healing, muscle loss, physical and functional decline, and lack of proper development.

Rationale 4: Delayed menopause. Delay in menopause is not a nutritional concern.

Global Rationale: Undernutrition can lead to delayed growth, compromised immune status, poor wound healing, muscle loss, physical and functional decline, and lack of proper development. Overnutrition results from excesses in nutrient intake or stores and can manifest itself in conditions such as obesity, hypertension, hypercholesterolemia, or toxic levels of stored vitamins or minerals. There are many causes of kidney failure that are not related to nutrition. Delay in menopause is not a nutritional concern.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.1: Define nutritional health.

Question 6

Type: MCSA

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.

Correct Answer: 3

Rationale 1: Get assistance to measure the child from head to toe in prone position. The nurse may enlist help from others to measure, but the measurement is from head to heel, not head to toe, and not in prone position.

Rationale 2: Wait until the child is sleeping and hold the child upright in front of a tape measure attempting for the best accuracy possible. It is incorrect to hold a client in a standing position to obtain a height measurement, either with the client awake or asleep.

Rationale 3: Place the child in a supine position and measures from the crown of the head to the heel while holding the legs straight. Recumbent length is obtained on persons who cannot stand freely for height measurements. The length is measured using a device, or by having the person lie flat in the supine position and measuring from the crown of the head to the heel with toes pointed upward and knees straight.

Rationale 4: Have the mother to assist the child in standing in front of a tape measure. It is incorrect to hold a client in a standing position to obtain a height measurement, either with the client awake or asleep.

Global Rationale: Recumbent length is obtained on persons who cannot stand freely for height measurements. The length is measured using a device, or by having the person lie flat in the supine position and measuring from the crown of the head to the heel with toes pointed upward and knees straight. It is incorrect to hold a client in a standing position to obtain a height measurement, either with the client awake or asleep. The nurse may enlist help from others to measure, but the measurement is from head to heel, not head to toe, and not in prone position.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet history.

Question 7

Type: MCSA

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

Correct Answer: 3

Rationale 1: Folate level. Folate and calcium levels may not be affected by PICA.

Rationale 2: Calcium levels. Folate and calcium levels may not be affected by PICA.

Rationale 3: Plasma lead level. Lead levels should be obtained in pregnant women reporting PICA because the soil eaten can be a source of environmental contamination.

Rationale 4: Hair analysis. Hair analysis may yield information about other issues but is not appropriate given the above scenario.

Global Rationale: PICA refers to the craving and ingestion of nonfood substances. Lead levels should be obtained in pregnant women reporting PICA because the soil eaten can be a source of environmental contamination. Folate and calcium levels may not be affected. Hair analysis may yield information about other issues but is not appropriate given the above scenario.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.2: Outline risk factors that affect nutritional health status.

Question 8

Type: MCSA

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

Correct Answer: 2

Rationale 1: Decubiti. Overweight clients may be at an increased risk for the development of decubiti but this is not a direct finding associated with a hip fracture.

Rationale 2: Degenerative joint disease. Overweight and obesity are risk factors for degenerative joint disease and functional and mobility problems as a result of the stressors on the joints from the excess weight.

Rationale 3: Chronic pain. There is no relationship between the clients weight, possible hip fracture and the presence of chronic pain.

Rationale 4: Stroke. There is inadequate information to support the risk for stroke.

Global Rationale: Overweight and obesity are risk factors for degenerative joint disease and functional and mobility problems. Overweight clients may be at an increased risk for the development of decubiti but this is not a direct finding associated with a hip fracture. There is no relationship between the clients weight, possible hip fracture and the presence of chronic pain. There is inadequate information to support the risk for stroke.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 9.2: Outline risk factors that affect nutritional health status.

Question 9

Type: MCSA

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

Correct Answer: 4

Rationale 1: One cup. One cup is larger than the recommended portion size for animal proteins.

Rationale 2: Size of a balled fist. A balled fist represents a cup-sized serving, which is too large for a portion of animal proteins.

Rationale 3: Five ounces. The recommended portion size for animal proteins is 3 ounces.

Rationale 4: Three ounces. The recommended portion size for animal proteins is 3 ounces, or a portion approximately the same size as a deck of cards.

Global Rationale: The recommended portion size for animal proteins is 3 ounces, which can be correctly estimated by comparing to the size of a deck of cards. The size of a balled fist is too large for a serving of animal proteins. Five ounces exceeds the recommend amount for protein intake during a single serving.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet history data.

Question 10

Type: MCMA

The nurse has reviewed the assessment findings for a recently admitted client. The nurse notes the clients dietary intake of the vitamin B complex to be lacking. Which of the findings confirm this deficiency?

Standard Text: Select all that apply.

1. Loss of fat

2. Muscle wasting

3. Hyporeflexia

4. Spoon nails

5. Ataxia

Correct Answer: 3,5

Rationale 1: Loss of fat. A series of vitamins make up the vitamin B complex. These vitamins are found in meat products and whole grains. A loss of fat is associated with a deficiency in protein or overall caloric intake.

Rationale 2: Muscle wasting. A series of vitamins make up the vitamin B complex. These vitamins are found in meat products and whole grains. A loss of muscle tissue is associated with a lack of protein intake.

Rationale 3: Hyporeflexia. A series of vitamins make up the vitamin B complex. These vitamins are found in meat products and whole grains. Thiamine is also known as Vitamin B1. It is responsible for nervous system functioning. Thiamine deficiency is associated with hyporeflexia.

Rationale 4: Spoon nails. Spoon nails are noted with a lack of iron intake.

Rationale 5: Ataxia. A series of vitamins make up the vitamin B complex. These vitamins are found in meat products and whole grains. Vitamin B12 is also referred to as Cobalamin. Vitamin B12 deficiencies are associated with ataxia.

Global Rationale: A series of vitamins make up the vitamin B complex. These vitamins are found in meat products and whole grains. Thiamine is also known as vitamin B1. It is responsible for nervous system functioning. Thiamine deficiency is associated with hyporeflexia. Vitamin B12 is also referred to as Cobalamin. Vitamin B12 deficiencies are associated with ataxia. A lack of caloric intake and protein deficiency is associated with a loss of fat. Protein deficiencies are also associated with muscle wasting. Spoon nails are seen with iron deficiencies.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 9.6: Differentiate between normal and abnormal findings in a nutritional assessment.

Question 11

Type: HOTSPOT

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.

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Correct Answer:

Rationale : The waist circumference may be used to assess for overnutrition in a client. It is not useful for determining overnutrition in a pregnant female or in the client with ascites.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9. 9: Determine specific nutritional assessment techniques and tools appropriate for unique stages in the life span.

Question 12

Type: MCMA

A Bioelectrical Impedance Analysis (BIA) is being performed on a client. Which of the following is associated with this test?

Standard Text: Select all that apply.

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 clients foot.

5. Place electrodes on the dorsal surface of the clients hand.

Correct Answer: 3,4,5

Rationale 1: Instruct the client to be NPO for 6 to 8 hours prior to the assessment. Altered hydration and altered skin temperature will cause measurement error by altering electrical current flow. Clients should be well hydrated when employing BIA technology, or dehydration will slow conductivity and give a falsely high body fat measurement.

Rationale 2: Instruct the client to discontinue all vitamin and mineral supplementation for 24 hours prior to the assessment. Calculations are based on the knowledge that muscle and fluids have a higher electrolyte and water content than does fat and thus conduct electrical current differently. Discontinuation of vitamin and mineral supplementation does not impact test findings.

Rationale 3: Instruct the client to lie in a supine position during the assessment. During the assessment the client will be instructed to lie in a supine position.

Rationale 4: Place electrodes on the dorsal surface of the clients foot. Electrodes are placed on the dorsal surface of the clients foot for the test.

Rationale 5: Place electrodes on the dorsal surface of the clients hand. Electrodes are placed on the dorsal surface of the clients hand for the test.

Global Rationale: Bioelectrical impedance analysis (BIA) is a noninvasive tool for assessing body composition employing principles of electroconduction through water, muscle, and fat. In traditional BIA, electrodes are placed on the dorsal surfaces of the right foot and hand with the client in the supine position on a nonconductive surface. Calculations are based on the knowledge that muscle and fluids have a higher electrolyte and water content than does fat and thus conduct electrical current differently. Altered hydration and altered skin temperature will cause measurement error by altering electrical current flow. Clients should be well hydrated when employing BIA technology, or dehydration will slow conductivity and give a falsely high body fat measurement. Clients cannot be placed as NPO status prior to the testing for 6 to 8 hours as this would alter the readings. The use of vitamin and mineral supplementation will not impact test findings.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.6: Describe existing validated nutritional assessment tools.

Question 13

Type: MCSA

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

Correct Answer: 3

Rationale 1: Congestive Heart Failure. There is no indication the client has cardiac problems.

Rationale 2: Dehydration.There is no indication the clients hydration status is compromised.

Rationale 3: Undernutrition. Undernutrition can lead to growth faltering, compromised immune status, poor wound healing, muscle loss, physical and functional decline, and lack of proper development. The clients weight changes indicate a lack of nutritional intake.

Rationale 4: Hypoglycemia. There is no indication the client has alterations in endocrine function.

Global Rationale: Undernutrition, also called malnutrition, describes health effects of insufficient nutrient intake or stores. Children who drop at least 2 percentile bands are at risk for undernutrition. There are no indications the client has cardiac-healthrelated concerns. Hypoglycemia is not applicable in this situation.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment into the nursing care process.

Question 14

Type: MCSA

The nurse is performing anthropometric measurements on a client in the clinic setting. The nurse would use which of the following definitions of this term when explaining this to the client?

1. The assessment is obtained by subtracting the height in centimeters from the weight in pounds and multiplying by 2.

2. The assessment includes any scientific measurement of the body for nutritional analysis.

3. The measurements include the use of growth chart evaluations to plot height and weight.

4. The measurement estimates skinfold thicknesses.

Correct Answer: 2

Rationale 1: The assessment is obtained by subtracting the height in centimeters from the weight in pounds and multiplying by 2. Anthropometric measurements are specific body measurements such as height, weight, and measurement of body fat. It does not utilize the calculation of weight and height in this manner.

Rationale 2: The assessment includes any scientific measurement of the body for nutritional analysis. Anthropometric measurements are any scientific measurements of the body.

Rationale 3: The measurements include the use of growth chart evaluations to plot height and weight. Anthropometric measurements are any scientific measurements of the body. They are not simply growth chart evaluations.

Rationale 4: The measurement estimates skinfold thicknesses. Anthropometric measurements are any scientific measurements of the body. They may include height, weight, measurement of body fat, and muscle composition. They may include measurements of skinfold thickness, not estimations.

Global Rationale: Anthropometric measurements are any scientific measurements of the body. They may include height, weight, measurement of body fat, and muscle composition. They may include measurements of skin fold thickness. They are not simply growth chart evaluations or calculations using combinations of numbers.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.9: Determine specific nutritional assessment techniques and tools appropriate for unique stages in the life span.

Question 15

Type: MCSA

The nurse is calculating the percent weight change of a 40-year-old female, weighing 156 pounds 1 month ago, and 140 pounds on current examination. The nurse would correctly record:

1. 5%

2. 10%

3. 12%

4. 14.3%

Correct Answer: 2

Rationale 1: 5%: A 5% weight loss would result in a weight of approximately 146 lb.

Rationale 2: 10%: A weight loss of 15% would result in a weight of approximately 141 lb.

Rationale 3: 12%: A weight loss of 12% would result in a weight of approximately 137 lb.

Rationale 4: 14.3%: A weight loss of 14.3% would result in a weight of approximately 134 lb.

Global Rationale: The formula for calculating percent weight change is: [156 lbs 140 lbs/156 lbs] x 100. These calculations yield an answer of 10 percent.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet history data.

Question 16

Type: MCMA

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?

Standard Text: Select all that apply.

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

Correct Answer: 2,3,4,5

Rationale 1: Alcohol abuse. Alcohol abuse is statistically linked to undernutrition.

Rationale 2: Sedentary lifestyle. The lack of calorie burning activity of a sedentary lifestyle is associated with overnutrition and weight gain.

Rationale 3: Excess intake of fat, sugar, calories, or other nutrients. Is commonly linked to overnutrition and weight gain.

Rationale 4: Lack of knowledge about food preparation. Food preparation may result in overnutrition as unhealthy techniques may be employed.

Rationale 5: Lack of knowledge about portion sizes. Portion control is key in the management of weight gain and loss. Lack of knowledge about portion control may result in over eating.

Global Rationale: Overnutrition results from excesses in nutrient intake or stores and can manifest itself in conditions such as obesity, hypertension, hypercholesterolemia, or toxic levels of stored vitamins or minerals. Sedentary lifestyles are linked to overnutrition. Individuals who are inactive typically require a lower caloric intake and will burn a lower number of calories. An excessive intake of fat, sugar, calories, and other nutrition places an individual at risk for overnutrition. Individuals who have a lack of knowledge concerning food preparation may fix and consume foods that are not nutritionally balanced, possibly increasing their risk for overnutrition. Knowledge of recommended portion sizes helps to ensure adequate nutritional intake. A lack of portion size recommendations may result in overeating. Alcohol abuse is statistically linked to undernutrition.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.2: Outline risk factors that affect nutritional health status.

Question 17

Type: MCMA

The graduate nurse in orientation notices that a dietician evaluates each postoperative clients chart. They know that this is done primarily to:

Standard Text: Select all that apply.

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.

Correct Answer: 2,3,4

Rationale 1: Meet a regulatory agency requirement. Although the collection of dietary information may be needed to meet the requirements of a regulatory agency, it is not the priority action in this situation.

Rationale 2: Determine nutritional needs. The assessment of a clients nutritional health requires a collaborative approach by multidisciplines. Postoperative clients may have different nutritional needs to promote healing.

Rationale 3: Check for any cultural dietary considerations. The nutritional selections suggested need to incorporate a clients religious or cultural considerations, or the plan will not be a feasible one for the client.

Rationale 4: Check to see if there are any potential food-drug interactions. As medications may change postoperatively, assessing for potential interactions with foods may prevent a problem in the future.

Rationale 5: Assess for overnutrition. Concerns regarding overnutrition are not the most important for the client who has recently had surgery.

Global Rationale: The evaluation of the clients postoperative chart by the dietician is done to assess the nutritional needs of the client. Clients in the postoperative phase of their care are attempting to heal. Healing is facilitated by adequate nutritional intake. The incorporation of cultural dietary preferences will best ensure that the client eat the foods provided by the facility and promote adequate nutritional intake. The potential for food-drug interactions must be included in the plan of care. Medications may be changed in the postoperative period warranting the assessment. Determination of these potential interactions will help to prevent complications in the client. The review of the postoperative chart may be a requirement of certain regulatory agencies but is not the most important factor. The risk for overnutrition may exist for the client but is not the primary focus for the assessment of the chart during the postoperative period.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet history.

Question 18

Type: MCSA

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 dont need to look in my mouth to see what is wrong with me! The nurses 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.

Correct Answer: 4

Rationale 1: A complete physical exam must be performed. The completion of a physical examination is needed during the admission process, but it is not the most important reason for the oral examination for this client.

Rationale 2: To assess for poorly-fitting dentures. The clients poor nutritional status may be the result of poorly fitting dentures. This will need to be determined, but it is not the most important reason for completing this portion of the assessment.

Rationale 3: To assess oral lesions. The presence of oral lesions may impact the ability of the client to have adequate nutritional intake. The assessment for the presence of the lesions important but not as important as the determination of the presence and degree of dehydration.

Rationale 4: To assess mucus membranes. The condition of the mucous membranes is the most important rationale for the assessment of the oral cavity. The determination of the presence and degree of dehydration is key in beginning the clients treatment.

Global Rationale: Poor dental health may contribute to malnutrition. If a client has oral ulcerations in the mouth, poorly-fitting dentures, decaying or loose teeth, it may be painful to eat or drink. This could cause a client to have a limited oral intake of food and fluids. Assessment of mucous membranes for moistness and color is part of an assessment when considering dehydration.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.8: Differentiate between normal and abnormal findings in a nutritional assessment.

Question 19

Type: MCSA

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 nurses 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.

Correct Answer: 1

Rationale 1: If you become pregnant, you will already be taking folic acid. The client in the scenario is of childbearing age. Folic acid is essential for all women of childbearing potential. It is important for a healthy outcome of a pregnancy. Some women are not aware of being pregnant at first and are not already taking folic acid. By suggesting a supplement, it will already be present in the body if the woman becomes pregnant.

Rationale 2: Everyone should take vitamin supplements. Not everyone needs vitamin supplements or have low folic acid levels if their dietary intake is balanced and appropriate.

Rationale 3: Folic acid can help with your chances of getting pregnant. Folic acid is a vitamin. Not everyone needs vitamin supplements or have low folic acid levels if their dietary intake is balanced and appropriate.

Rationale 4: Most people do not get enough folic acid. Not everyone needs vitamin supplements or have low folic acid levels if their dietary intake is balanced and appropriate.

Global Rationale: Folic acid is essential for all women of childbearing potential. It is important for a healthy outcome of a pregnancy. It does not help a person become pregnant. Some women are not aware of being pregnant at first and are not already taking folic acid. By suggesting a supplement, it will already be present in the body if the woman becomes pregnant. Not everyone needs vitamin supplements or have low folic acid levels if their dietary intake is balanced and appropriate.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.3: Discuss the objectives described in Healthy People 2020 which relate to nutrition.

Question 20

Type: MCSA

A nurse is preparing to review an overweight clients 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

Correct Answer: 3

Rationale 1: Measuring cups. Having a client use measuring cups, food scales, and plastic containers can be helpful when preparing foods at home, but not realistic when estimating portion sizes at restaurants.

Rationale 2: Food cups. Having a client use measuring cups, food scales and plastic containers can be helpful when preparing foods at home, but not realistic when estimating portion sizes at restaurants.

Rationale 3: Everyday items such as a deck of cards. By using everyday items such as a deck of cards to determine meat sizes or a golf ball to determine a tablespoon measurement, a client can learn to visually estimate appropriate portions. This visual teaching method may be a useful and easy approach for clients.

Rationale 4: Plastic containers. Having a client use measuring cups, food scales, and plastic containers can be helpful when preparing foods at home, but not realistic when estimating portion sizes at restaurants.

Global Rationale: Determining portion sizes is difficult for most clients. When keeping a diet diary or doing a diet recall, the client may be confused if the number of meals is adequate but he continues to gain weight. Having a client use measuring cups, food scales, and plastic containers can be helpful when preparing foods at home, but not realistic when estimating portion sizes at restaurants. By using everyday items such as a deck of cards to determine meat sizes or a golf ball to determine a tablespoon measurement, a client can learn to visually estimate appropriate portions. This visual teaching method may be a useful and easy approach for clients.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment into the nursing care process.

Question 21

Type: MCSA

An overweight female client is reluctant to get on the scales at the healthcare providers office. She verbalizes that she does not want to know how much she actually weighs. The nurses 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.

Correct Answer: 2

Rationale 1: The doctor requires all of her clients to be weighed. Explaining that the weight is required does not really meet the concerns being voiced by the client.

Rationale 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. A clients weight is part of the anthropometric measurements. The height, weight, and body fat and muscle composition are part of these measurements. By using these values with a physical assessment, a clients nutritional status may be evaluated. Promoting the confidentiality of the procedure may help to reassure and calm the client.

Rationale 3: I really do not like it either, but it has to be done. Forcing the client is a violation of rights.

Rationale 4: We can just use your weight from your visit last year. Using a weight that is a year old will not accurately reflect a current trend or change. The data can still be gathered for a nutritional assessment and the clients wishes met by measuring the clients weight without verbalizing what it is.

Global Rationale: A clients weight is part of the anthropometric measurements. The height, weight, and body fat and muscle composition are part of these measurements. By using these values with a physical assessment, a clients nutritional status may be evaluated. Forcing the client is a violation of rights. Using a weight that is a year old will not accurately reflect a current trend or change. The data can still be gathered for a nutritional assessment and the clients wishes met by measuring the clients weight without verbalizing what it is.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment into the nursing care process.

Question 22

Type: MCSA

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

Correct Answer: 3

Rationale 1: A 21-year-old female who has just begun college and has lost 5 pounds in the first semester. The female that just began college has had activity and nutrition changes.

Rationale 2: A 2 year old whose mother stated that he seems to be growing faster than she can buy him clothes. Toddlers experience growth spurts that are normal physiological processes.

Rationale 3: A 50-year-old male who reported that he lost 10 pounds in 6 weeks without even trying. Unintentional weight loss is considered clinically significant and requires further assessment. The cause is not readily apparent and may be due to a disease process.

Rationale 4: A 35-year-old female who has gained 15 pounds in a year after the birth of her first child. In the first year after the birth of a child a woman may increase body weight as a result of diet, activity, and hormonal changes.

Global Rationale: Unintentional weight loss is considered clinically significant and requires further assessment. The cause is not readily apparent and may be due to a disease process. The female that just began college has had activity and nutrition changes. The 2 year old seems to be growing sufficiently and the 35-year-old female has had recent body changes.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.8: Differentiate between normal and abnormal findings in a nutritional assessment.

Question 23

Type: MCSA

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 teams 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.

Correct Answer: 3

Rationale 1: BMI reports are best used for athletes who engage in body-building activities. BMI classifications do not take into account physical variations or athletic levels of individuals.

Rationale 2: BMI classifications should be used only on older adults. The BMI is a tool that may be used on adults, not just older adults.

Rationale 3: BMI classifications do not take into account racial or physical variations. The BMI should not be used exclusively to evaluate weight or nutritional recommendations. It is not reflective of variations of body fat, muscle size or bone mineral content, racial or athletic level of an individual.

Rationale 4: Nutritional status of a college student should be evaluated using skinfold measurements. Skinfold measurement alone may not provide an overall nutrition evaluation.

Global Rationale: The BMI should not be used exclusively to evaluate weight or nutritional recommendations. It is not reflective of variations of body fat, muscle size or bone mineral content, racial or athletic level of an individual. Using this tool in addition to other nutritional screenings such as skinfold measurement, physical assessment and interviewing will provide the best overall evaluation and recommendation base. The cost of using the tool is not a consideration. The tool is for use in adults, not just older adults. Skinfold measurement alone may not provide an overall nutrition evaluation.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9.9: Determine specific nutritional assessment techniques and tools appropriate for unique stages in the life span.

Question 24

Type: MCSA

A 78-year-old female client is in the healthcare providers office for a routine physical exam. She asks for an explanation of why skinfold measurements are not done on her anymore. The nurses 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.

Correct Answer: 2

Rationale 1: Those tests are no longer recommended to assess BMI. Expressing to the client that the tests are no longer recommended does not meet the request for information. In addition, the test is not used to determine BMI.

Rationale 2: As a person ages, the test is not as accurate. The subcutaneous fat distribution and total body fat composition change as an adult ages. The reference values for older adults and suggested locations of skinfold measurements requires further investigation and data collection to be accurate.

Rationale 3: The BMI (body mass index) test is easier to use. The ease of the test is not the reason for the change in the assessments being performed.

Rationale 4: A detailed dietary history will give us the information that we need. A diet history is an important part of a nutritional assessment, but does not give body composition values.

Global Rationale: The subcutaneous fat distribution and total body fat composition change as an adult ages. The reference values for older adults and suggested locations of skinfold measurements require further investigation and data collection to be accurate. Skinfold measurements are not recommended to provide BMI information. They are intended to assess subcutaneous fat distribution. The reference values are still used in adults, but variations such as race, gender, and fitness level need to be considered. The BMI is easier to use, but does not give as detailed data about actual body fat and muscle mass. The ease of the test is not the basis for the changes in assessment being reported by the client. A diet history is an important part of a nutritional assessment, but does not give body composition values.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.9: Determine specific nutritional assessment techniques and tools appropriate for unique stages in the life span.

Question 25

Type: MCSA

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

Correct Answer: 4

Rationale 1: Female gender. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels.

Rationale 2: Male gender. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels.

Rationale 3: Higher socioeconomic levels. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels.

Rationale 4: Lower educational levels. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels.

Global Rationale: Some clients may underreport portions of the nutritional history during the data collection process. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels. Additionally, alcohol and drug use are frequently underreported. A nonjudgmental approach during the nutritional history will provide an environment conducive to full answers by the client.

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment into the nursing care process.

Question 26

Type: MCSA

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.

Correct Answer: 2

Rationale 1: The prevalence of overnutrition is greatest in African American males. The prevalence of overnutrition is highest in the Mexican American male.

Rationale 2: Hypertension is highest in the African American population. Hypertension is highest in the African American population.

Rationale 3: Adults living at the poverty line have the greatest risk for undernutrition. The risk for overnutrition is most associated with a lower socieoeconomic status and reduced levels of education

Rationale 4: Iron deficiency anemia is a prevalent problem in the African American population. Iron deficiency anemia is not documented as a prevalent problem in the African American population

Global Rationale: The prevalence of overnutrition is highest in the Mexican American male. Hypertension is highest in the African American population. The risk for overnutrition is most associated with a lower socieoeconomic status and reduced levels of education. Iron deficiency anemia is not documented as a prevalent problem in the African American population.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9.2: Outline risk factors that affect nutritional health status.

Question 27

Type: MCSA

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.

Correct Answer: 4

Rationale 1: It is important for your health that you closely adhere to the recommendations of height and weight tables to avoid weight related complications. Height-weight tables have been used in the past to assess body weight in adults, but are no longer a standard. Use of such height-weight tables has the same limitations as does use of BMI as a sole indicator of weight status.

Rationale 2: Height and weight tables are highly subjective. Height-weight tables have been used in the past to assess body weight in adults, but are no longer a standard. Use of such height-weight tables has the same limitations as does use of BMI as a sole indicator of weight status.

Rationale 3: Using height and weight tables can be problematic as they are often inaccurate. Height-weight tables have been used in the past to assess body weight in adults, but are no longer a standard. Use of such height-weight tables has the same limitations as does use of BMI as a sole indicator of weight status.

Rationale 4: Height and weight tables have significant limitations for predicting weight status of an individual. Height-weight tables have been used in the past to assess body weight in adults, but are no longer a standard. Use of such height-weight tables has the same limitations as does use of BMI as a sole indicator of weight status.

Global Rationale: Height-weight tables have been used in the past to assess body weight in adults, but are no longer a standard. Use of such height-weight tables has the same limitations as does the use of BMI as a sole indicator of weight status. Differences in body composition go largely unaccounted for and the clinician must remember to assess each person for these individual differences.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.6: Describe existing validated nutritional assessment tools

Question 28

Type: MCMA

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?

Standard Text: Select all that apply.

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.

Correct Answer: 1,2,5

Rationale 1: There are no differences in the percentage of body fat needed by girls and boys during the teen years. The recommended body fat percentages for females is greater than that of males.

Rationale 2: The lower I can get my body fat percentage, the better. The absolute minimum levels of body fat are still being studied; however, experts do believe that there are minimum body fat percentages.

Rationale 3: The body fat percentages needed by females is higher than that of males. A range of 12% to 20% body fat in men and 20% to 30% in women has been suggested for health.

Rationale 4: There are no absolute standards for body fat percentages needed by men and women. Research aimed at development of future standards and references for body fat percentage will address the relationship between BMI and body fat percentage and allow the nurse a clearer assessment of body composition traits associated with health risks. Age-specific recommendations are also needed.

Rationale 5: Persons having body fat percentages greater than 20% are at an increased risk for illness. Standards of body fat percentage that are associated with health or morbidity and mortality have not been established. Many sources agree that a minimum essential body fat percentage exists.

Global Rationale: During the teen years differing percentages of body fat are needed by girls and boys. Females need a higher percentage of body fat. A range of 12% to 20% body fat in men and 20% to 30% in women has been suggested for health. The absolute minimum levels of body fat are still being studied; however, experts do believe that there are minimum body fat percentages. Research aimed at development of future standards and references for body fat percentage will address the relationship between BMI and body fat percentage and allow the nurse a clearer assessment of body composition traits associated with health risks. Age-specific recommendations are also needed. Standards of body fat percentage that are associated with health or morbidity and mortality have not been established. Many sources agree that a minimum essential body fat percentage exists.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9.4: Identify physical and laboratory parameters utilized in a nutrition assessment.

Question 29

Type: MCSA

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.

Correct Answer: 4

Rationale 1: I have been taking all of them for over 20 years now. The length of time the client has been taking a potentially excessive level of vitamin supplements is not the greatest concern. The larger concern is the potential belief that they will protect him from illness by offsetting nutritional deficits. The age of the client will increse the potential dangers of this practice as the older adult body may change how the supplements affect the body.

Rationale 2: My doctor in my old town recommended most of them. The current physican of record will need notification to review the medications being taken. They may impact currently prescribed medications.

Rationale 3: My wife also takes the same things. The health of the spouse may be impacted by oversupplementation but the greatest current concern is the potential risks being faced by the client in the scenario.

Rationale 4: I know that I do not eat right all of the time, so they will keep me healthy. Dietary intake is the best means to meet nutritional requirements. Oversupplementation may present health-related concerns.

Global Rationale: Oversupplementation of herbs, vitamins, minerals, and sports products may be dangerous. The older adult has physiologic body changes that may change how the supplements affect the body. Many supplements have effects on medications the client may be taking, whether they are over-the-counter or prescribed medications. Use of supplements is not intended to replace healthy nutrition on a routine basis. This client needs education before there are problems. The other responses may require further investigation and an assessment of overall nutrition, but these responses do not indicate a current problem.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.8: Differentiate between normal and abnormal findings in a nutritional assessment.

Question 30

Type: HOTSPOT

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.

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The tricep skinfold (TSF) is the site most often used to estimate subcutaneous fat because of easy access to this measurement in most situations. Tricep measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.4: Identify physical and laboratory parameters utilized in a nutrition assessment.

Question 31

Type: MCSA

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?

Correct Answer: 3

Rationale 1: Are you eating more than you should? The focused interview of the clients nutritional concerns will include asking the client to recall intake for the past 24 hours. The 24-hour period will provide insight into the dietary intake of the client by providing a snapshot of food selections and eating patterns. It is important not to appear judgmental during the focused interview. Asking the client if she is eating large quantities of food is subjective, may be interpreted by the client in a negative manner and will likely not yield the needed information.

Rationale 2: Do you eat large quantities of carbohydrates? Questioning the client about carbohydrate directly is not the best tactic. The client may not be clear about which foods are sources of carbohydrates. Better information about the dietary intake can be obtained with a dietary recall.

Rationale 3: Please tell me about what foods and beverages you have consumed for the past 24 hours. The focused interview of the clients nutritional concerns will include asking the client to recall intake for the past 24 hours. The 24-hour period will provide insight into the dietary intake of the client by providing a snapshot of food selections and eating patterns.

Rationale 4: Have you noticed your energy level has decreased with your recent weight gain? Energy levels may change with weight gain. The purpose of the focused interview at this point to so obtain information to guide the physical assessment in relation to nutrition and weight gain.

Global Rationale: The focused interview of the clients nutritional concerns will include asking the client to recall intake for the past 24 hours. The 24-hour period will provide insight into the dietary intake of the client by providing a snapshot of food selections and eating patterns. It is important not to appear judgmental during the focused interview. Asking the client if she is eating large quantities of food is subjective, may be interpreted by the client in a negative manner and will likely not yield the needed information. Questioning the client about carbohydrate directly is not the best tactic. The client may not be clear about which foods are sources of carbohydrates. Better information about the dietary intake can be obtained with a dietary recall. Energy levels may change with weight gain. The purpose of the focused interview at this point is to obtain information to guide the physical assessment in relation to nutrition and weight gain.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.7: Develop questions to be used when completing a focused interview.

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