Deck 5: Adult Health and Nutritional Assessment

Question 1

A school nurse is teaching a 14-year-old girl of normal weight some of the key factors necessary to maintain good nutrition in this stage of her growth and development. What interventions should the nurse most likely prioritize?

A) Decreasing her calorie intake and encouraging her to maintain her weight to avoid obesity
B) Increasing her BMI, taking a multivitamin, and discussing body image
C) Increasing calcium intake, eating a balanced diet, and discussing eating disorders
D) Obtaining a food diary along with providing close monitoring for anorexia

Answer 1

Increasing calcium intake, eating a balanced diet, and discussing eating disorders

Question 2

A nurse is conducting a health assessment of an adult patient when the patient asks, Why do you need all this health information and who is going to see it? What is the nurses best response?

A) Please do not worry. It is safe and will be used only to help us with your care. Its accessible to a wide variety of people who are invested in your health.
B) It is good you asked and you have a right to know; your information helps us to provide you with the best possible care, and your records are in a secure place.
C) Your health information is placed on secure Web sites to provide easy access to anyone wishing to see your medical records. This ensures continuity of care.
D) Health information becomes the property of the hospital and we will make sure that no one sees it. Then, in 2 years, we destroy all records and the process starts over.

Answer 2

It is good you asked and you have a right to know; your information helps us to provide you with the best possible care, and your records are in a secure place.

Question 3

The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patients language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection?

A) Have a family member provide the data.
B) Obtain the data from the old chart and physicians assessment.
C) Obtain the data only from the patient, prioritizing aspects that the patient understands.
D) Collect all possible data from the patient and have the family supplement missing details.

Answer 3

Collect all possible data from the patient and have the family supplement missing details.

Question 4

You are the nurse assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. You note bruising to the patients upper arm that correspond to the outline of fingers as well as yellow bruising around her left eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising?

A) Is anyone physically hurting you?
B) Tell me about your relationships.
C) Do you want to see a social worker?
D) Is there something you want to tell me?

Question 5

You are the nurse performing a health assessment of an adult male patient. The man states, The doctor has already asked me all these questions. Why are you asking them all over again? What is your best response?

A) This history helps us determine what your needs may be for nursing care.
B) You are right; this may seem redundant and Im sure that its frustrating for you.
C) I want to make sure your doctor has covered everything thats important for your treatment.
D) I am a member of your health care team and we want to make sure that nothing falls through the cracks.

Question 6

You are taking a health history on an adult patient who is new to the clinic. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the primary significance of this information to the health history?

A) The patient may be at risk for developing diabetes.
B) The patient may need teaching on the effects of diabetes.
C) The patient may need to attend a support group for individuals with diabetes.
D) The patient may benefit from a dietary regimen that tracks glucose intake.

Question 7

A registered nurse is performing the admission assessment of a 37-year-old man who will be treated for pancreatitis on the medical unit. During the nursing assessment, the nurse asks the patient questions related to his spirituality. What is the primary rationale for this aspect of the nurses assessment?

A) The patients spiritual environment can affect his physical activity.
B) The patients spiritual environment can affect his ability to communicate.
C) The patients spiritual environment can affect his quality of sexual relationships.
D) The patients spiritual environment can affect his response to illness.

Question 8

A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patients statement?

A) The patient does not understand the principles of nutrition.
B) This is an aspect of the patients religious practice.
C) This constitutes a nursing diagnosis of Risk for Imbalanced Nutrition.
D) This is an example of the patients coping strategies.

Question 9

You are beginning your shift on a medical unit and are performing assessments appropriate to each patients diagnosis and history. When assessing a patient who has an acute staphylococcal infection, what
Is the most effective technique for assessing the lymph nodes of the patients neck?

A) Inspection
B) Auscultation
C) Palpation
D) Percussion

Question 10

In your role as a school nurse, you are working with a female high school junior whose BMI is 31 . When planning this girls care, you should identify what goal?

A) Continuation of current diet and activity level
B) Increase in exercise and reduction in calorie intake
C) Possible referral to an eating disorder clinic
D) Increase in daily calorie intake

Question 11

During your integumentary assessment of an adult female patient, you note that the patient has dry, dull, brittle hair and dry, flaky skin with poor turgor. When planning this patients nursing care, you should prioritize interventions that address what problem?

A) Inadequate physical activity
B) Ineffective personal hygiene
C) Deficient nutritional status
D) Exposure to environmental toxins

Question 12

A home care nurse is teaching meal-planning to a patients son who is caring for his mother during her recovery from hip replacement surgery. Which of the following meals indicates that the son understands the concept of nutrition, based on the U.S. Department of Agricultures MyPlate?

A) Cheeseburger, carrot sticks, and mushroom soup with whole wheat crackers
B) Spaghetti and meat sauce with garlic bread and a salad
C) Chicken and pepper stir fry on a bed of rice
D) Ham sandwich with tomato on rye bread with peaches and yogurt

Question 13

You are assessing an 80 -year-old patient who has presented because of an unintended weight loss of 10 pounds over the past 8 weeks. During the assessment, you learn that the patient has ill-fitting dentures and a limited intake of high-fiber foods. You would be aware that the patient is at risk for what problem?

A) Constipation
B) Deficient fluid volume
C) Malabsorption of nutrients
D) Excessive intake of convenience foods

Question 14

You are teaching a nutrition education class that is being held for a group of older adults at a senior center. When planning your teaching, you should be aware that individuals at this point in the lifespan have which of the following?

A) A decreased need for calcium
B) An increased need for glucose
C) An increased need for sodium
D) A decreased need for calories

Question 15

You are the emergency department nurse obtaining a health history from a patient who has earlier told the triage nurse that she is experiencing intermittent abdominal pain. What question should you ask to elicit the probable reason for the visit and identify her chief complaint?

A) Why do you think your abdomen is painful?
B) Where exactly is your abdominal pain and when did it start?
C) What brings you to the hospital today?
D) What is wrong with you today?

Question 16

You are the nurse caring for a patient who is Native American who arrives at the clinic for treatment related to type 2 diabetes. Which question would best provide you with information about the role of food in the patients cultural practices and identify how the patients food preferences could be related to his problem?

A) Do you feel any of your cultural practices have a negative impact on your disease process?
B) What types of foods are served as a part of your cultural practices, and how are they prepared?
C) As a nonnative, I am unaware of your cultural practices. Could you teach me a few practices that may affect your care?
D) Tell me about foods that are important in your culture and how you feel they influence your diabetes.

Question 17

An 89-year-old male patient is wheelchair bound following a hemorrhagic stroke and has been living in a nursing home since leaving the hospital. He returns to the adjacent primary care clinic by wheelchair for follow-up care of hypertension and other health problems. The nurse would modify his health history to include which question?

A) Tell me about your medications: How do you usually get them each day?
B) Tell me about where you live: Do you feel your needs are being met, and do you feel safe?
C) Your wheelchair would seem to limit your ability to move around. How do you deal with that?
D) What limitations are you dealing with related to your health and being in a wheelchair?

Question 18

A 30-year-old man is in the clinic for a yearly physical. He states, I found out that two of my uncles had heart attacks when they were young. This alerts the nurse to complete a genetic-specific assessment. What component should the nurse include in this assessment?

A) A complete health history, including genogram along with any history of cholesterol testing or screening and a complete physical exam
B) A limited health history along with a complete physical assessment with an emphasis on genetic abnormalities
C) A limited health history and focused physical exam followed by safety-related education
D) A family history focused on the paternal family with focused physical exam and genetic profile

Question 19

A patient has a newly diagnosed heart murmur. During the nurses subsequent health education, he asks if he can listen to it. What would be the nurses best response?

A) Listening to the body is called auscultation. It is done with the diaphragm, and it requires a trained ear to hear a murmur.
B) Listening is called palpation, and I would be glad to help you to palpate your murmur.
C) Heart murmurs are pathologic and may require surgery. If you would like to listen to your murmur, I can provide you with instruction.
D) If you would like to listen to your murmur, Id be glad to help you and to show you how to use a stethoscope.

Question 20

In your role as a school nurse, you are performing a sports physical on a healthy adolescent girl who is planning to try out for the volleyball team. When it comes time to listen to the students heart and lungs, what is your best nursing action?

A) Perform auscultation with the stethoscope placed firmly over her clothing to protect her privacy.
B) Perform auscultation by holding the diaphragm lightly on her clothing to eliminate the scratchy noise.
C) Perform auscultation with the diaphragm placed firmly on her skin to minimize extra noise.
D) Defer the exam because the girl is known to be healthy and chest auscultation may cause her anxiety.

Question 21

A nurse who provides care in a campus medical clinic is performing an assessment of a 21 -year-old student who has presented for care. After assessment, the nurse determines that the patient has a BMI of 45. What does this indicate?

A) The patient is a normal weight.
B) The patient is extremely obese.
C) The patient is overweight.
D) The patient is mildly obese.

Question 22

A nurse is conducting a home visit as part of the community health assessment of a patient who will receive scheduled wound care. During assessment, the nurse should prioritize which of the following variables?

A) Availability of home health care, current Medicare rules, and family support
B) The community and home environment, support systems or family care, and the availability of needed resources
C) The future health status of the individual, and community and hospital resources
D) The characteristics of the neighborhood, and the patients socioeconomic status and insurance coverage

Question 23

You are performing the admission assessment of a patient who is being admitted to the postsurgical unit following knee arthroplasty. The patient states, Youve got more information on me now than my own family has. How do you manage to keep it all private? What is your best response to this patients concern?

A) Your information is maintained in a secure place and only those health care professionals directly involved in your care can see it.
B) Your information is available only to people who currently work in patient care here in the hospital.
C) Your information is kept electronically on a secure server and anyone who gets permission from you can see it.
D) Your information is only available to professionals who care for you and representatives of your insurance company.

Question 24

You are admitting an elderly woman who is accompanied by her husband. The husband wants to know where the information you are obtaining is going to be kept and you follow up by describing the system of electronic health records. The husband states, I sure am not comfortable with that. It is too easy for someone to break into computer records these days. What is your best response?

A) The Institute of Medicine has called for the implementation of the computerized health record so all hospitals are doing it.
B) Weve been doing this for several years with good success, so I can assure you that our records are very safe.
C) This hospital is as concerned as you are about keeping our patients records private. So we take special precautions to make sure no one can break into our patients medical records.
D) Your wifes records will be safe, because only people who work in the hospital have the credentials to access them.

Question 25

A family whose religion limits the use of some forms of technology is admitting their grandfather to your unit. They express skepticism about the fact that you are recording the admission data on a laptop computer. What would be your best response to their concerns?

A) Its been found that using computers improves our patients care and reduces their health care costs.
B) We have found that it is easier to keep track of our patients information this way rather than with pen and paper.
C) Youll find that all the hospitals are doing this now, and that writing information with a pen is rare.
D) The government is telling us we have to do this, even though most people, like yourselves, are opposed to it.

Question 26

You are performing a dietary assessment with a patient who has been admitted to the medical unit with community-acquired pneumonia. The patient wants to know why the hospital needs all this information about the way he eats, asking you, Are you asking me all these questions because I am Middle Eastern? What is your best response to this patient?

A) We always try to abide by foreign-born patients dietary preferences in order to make them comfortable.
B) We know that some cultural and religious practices include dietary guidelines, and we do not want to violate these.
C) We wouldnt want to feed you anything you only eat on certain holidays.
D) We know that patients who grew up in other countries often have unusual diets, and we want to accommodate this.

Question 27

You are orienting a new nursing graduate to your medical unit. The new nurse has been assisting an elderly woman, who is Greek, to fill out her menu for the next day. To what resource should you refer your colleague to obtain appropriate dietary recommendations for this patient?

A) The U.S. Department of Agricultures MyPlate
B) Evidence-based resources on nutritional assessment
C) Culturally sensitive materials, such as the Mediterranean Pyramid
D) A Greek cookbook that contains academic references

Question 28

In the course of performing an admission assessment, the nurse has asked questions about the patients first- and second-order relatives. What is the primary rationale for the nurses line of questioning?

A) To determine how many living relatives the patient has
B) To identify the familys level of health literacy
C) To identify potential sources of social support
D) To identify diseases that may be genetic

Question 29

The nurse is completing a family history for a patient who is admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The nurse should include questions that address which of the following health problems? Select all that apply.

A) Allergies
B) Alcoholism
C) Psoriasis
D) Hypervitaminosis
E) Obesity

Question 30

The admitting nurse has just met a new patient who has been admitted from the emergency department. As the nurse introduces himself, he begins the process of inspection. What nursing action should the nurse include during this phase of assessment?

A) Gather as many psychosocial details as possible.
B) Pay attention to the details while observing.
C) Write down as many details as possible during the observation.
D) Do not let the patient know he is being assessed.

Question 31

During a comprehensive health assessment, which of the following structures can the nurse best assess by palpation?

A) Intestines
B) Gall bladder
C) Thyroid gland
D) Pancreas

Question 32

During a health assessment of an older adult with multiple chronic health problems, the nurse practitioner is utilizing multiple assessment techniques, including percussion. What is the essential principle of percussion?

A) To assess the sound created by the body
B) To strike the abdominal wall with a soft object
C) To create sound over dead spaces in the body
D) To create vibration in a body wall

Question 33

A nurse practitioners assessment of a new patient includes each of the four basic assessment techniques. When using percussion, which of the following is the nurse able to assess?

A) Borders of the patients heart
B) Movement of the patients diaphragm during expiration
C) Borders of the patients liver
D) The presence of rectal distension

Question 34

A 51-year-old womans recent complaints of fatigue are thought to be attributable to iron-deficiency anemia. The patients subsequent diagnostic testing includes quantification of her transferrin levels. This biochemical assessment would be performed by assessing which of the following?

A) The patients urine
B) The patients serum
C) The patients cerebrospinal fluid
D) The patients synovial fluid

Question 35

An older adults unexplained weight loss of 15 pounds over the past 3 months has prompted a thorough diagnostic workup. What is the nurses rationale for prioritizing biochemical assessment when appraising a persons nutritional status?

A) It identifies abnormalities in the chemical structure of nutrients.
B) It predicts abnormal utilization of nutrients.
C) It reflects the tissue level of a given nutrient.
D) It predicts metabolic abnormalities in nutritional intake.

Question 36

A school nurse at a middle school is planning a health promotion initiative for girls. The nurse has identified a need for nutritional teaching. What problem is most likely to relate to nutritional problems in girls of this age?

A) Protein intake in this age group often falls below recommended levels.
B) Total calorie intake is often insufficient at this age.
C) Calcium intake is above the recommended levels.
D) Folate intake is below the recommended levels in this age group.

Question 37

A team of community health nurses has partnered with the staff at a youth drop-in center to address some of the health promotion needs of teenagers. The nurses have identified a need to address nutritional assessment and intervention. Which of the following most often occurs during the teen years?

A) Lifelong eating habits are acquired.
B) Peer pressure influences growth.
C) BMI is determined.
D) Culture begins to influence diet.

Question 38

A newly admitted patient has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment. What assessment parameters are included when assessing a patients nutritional status? Select all that apply.

A) Ethnic mores
B) BMI
C) Clinical examination findings
D) Wrist circumference
E) Dietary data

Question 39

The segment of the population who has a BMI lower than 24 has been found to be at increased risk for poor nutritional status and its resultant problems. What else is a low BMI associated with in the community-dwelling elderly?

A) High risk of diabetes
B) Increased incidence of falls
C) Higher mortality rate
D) Low risk of chronic disease

Question 40

Imbalanced nutrition can be characterized by excessive or deficient food intake. What potential effect of imbalanced nutrition should the nurse be aware of when assessing patients?

A) Masking the symptoms of acute infection
B) Decreasing wound healing time
C) Contributing to shorter hospital stays
D) Prolonging confinement to bed

Question 41

A nurse who has practiced in the hospital setting for several years will now transition to a new role in the community. How does a physical assessment in the community vary in technique from physical assessment in the hospital?

A) A physical assessment in the community consists of largely the same techniques as are used in the hospital.
B) A physical assessment made in the community does not require the privacy that a physical assessment made in the hospital setting requires.
C) A physical assessment made in the community requires that the patient be made more comfortable than would be necessary in the hospital setting.
D) A physical assessment made in the community varies in technique from that conducted in the hospital setting by being less structured.

Question 42

You are conducting an assessment of a patient in her home setting. Your patient is a 91-year-old woman who lives alone and has no family members living close by. What would you need to be aware of to aid in providing care to this patient?

A) Where the closest relative lives
B) What resources are available to the patient
C) What the patients financial status is
D) How many children this patient has