Question 1

A client has been diagnosed with undernutrition. Which health problem should the nurse consider as most likely contributing to this nutritional issue?
A) Problem swallowing
B) Too much body fluid
C) Sadness and depression
D) Difficulty voiding urine

Accepted Answer

The client with a problem swallowing would have difficulty taking in adequate amounts of food to maintain nutritional status. Too much body fluid would cause overhydration. Difficulty voiding urine would contribute to overhydration. Sadness and depression may reduce the appetite and reduce food intake however the most likely reason for undernutrition is the problem with swallowing.

Question 2

The nurse is concerned that a client is at risk for undernutrition. Which client statement caused the nurse to have this concern? (Select all that apply.)
A) "My dentures don't fit well anymore."
B) "I've been taking chemotherapy for lung cancer."
C) "I have been so sad and lonely since my wife died."
D) "I feel like there are sometimes I cannot stop eating."
E) "Each day, I take two doses of multivitamins instead of one."

Accepted Answer

People who are prone to developing undernutrition are those that may be unable to eat well due to a medical condition, altered functional status, a poor diet, or a low socioeconomic status. Depression and social isolation place people at risk for undernutrition. Chemotherapy can cause nausea and vomiting which is associated with undernutrition. It is important to have good oral health to be able to chew raw fruits and vegetables and other foods. People who take more than one recommended dose of a multivitamin are more prone to developing overnutrition. People who eat too much food develop issues with overnutrition due to an increased intake of nutrients, calories, saturated fats, vitamins, and minerals.
People who are prone to developing undernutrition are those that may be unable to eat well due to a medical condition, altered functional status, a poor diet, or a low socioeconomic status. Depression and social isolation place people at risk for undernutrition. Chemotherapy can cause nausea and vomiting which is associated with undernutrition. It is important to have good oral health to be able to chew raw fruits and vegetables and other foods. People who take more than one recommended dose of a multivitamin are more prone to developing overnutrition. People who eat too much food develop issues with overnutrition due to an increased intake of nutrients, calories, saturated fats, vitamins, and minerals.
People who are prone to developing undernutrition are those that may be unable to eat well due to a medical condition, altered functional status, a poor diet, or a low socioeconomic status. Depression and social isolation place people at risk for undernutrition. Chemotherapy can cause nausea and vomiting which is associated with undernutrition. It is important to have good oral health to be able to chew raw fruits and vegetables and other foods. People who take more than one recommended dose of a multivitamin are more prone to developing overnutrition. People who eat too much food develop issues with overnutrition due to an increased intake of nutrients, calories, saturated fats, vitamins, and minerals.

Question 3

A client develops aspiration pneumonia after a traumatic brain injury produced an impaired ability to swallow. Which activity should the nurse skip when caring for this client?
A) Nutrition history
B) Nutrition screening
C) Head-to-toe physical assessment
D) Laboratory-based diagnostic testing

Accepted Answer

This client has been admitted with aspiration pneumonia and has swallowing difficulties. Nutritional screening activities are provided for clients to determine if a full nutritional assessment is needed. Based on this client's diagnosis and history, this client needs a full nutritional assessment which includes the nutrition history assessment, physical assessment, and laboratory-based diagnostic testing. Nutritional screening activities would only indicate the client needs a full nutritional assessment.

Question 4

The nurse is performing a nutrition assessment on the client. Which information should the nurse document as laboratory data?
A) "Leukocytosis."
B) "Client using St. John's worst daily."
C) "Dental caries and poor oral health noted."
D) "Client lost 20 pounds during last 2 months."

Accepted Answer

Increased white blood cell count would be documented as a laboratory result. Weight loss would most likely be discovered when assessing the weight history during a nutritional screening, nutrition history, or during a physical assessment. Dental caries and poor oral health would be found during a physical assessment. Dietary supplement use would be discovered during the nutrition history.

Question 5

The nurse plans to complete nutritional assessments for a group of assigned clients. For which client would it be inappropriate for the nurse to complete a dietary recall?
A) Client with dementia
B) Client with polycystic kidney disease
C) Client with a history of Crohn disease
D) Client newly diagnosed with emphysema

Accepted Answer

During a diet recall, the client is prompted to remember all of the foods and beverages that have been ingested over the last 24 hours. The client who has difficulty remembering events may have trouble with this activity. Clients diagnosed with emphysema, Crohn disease, and polycystic kidney disease would be able to provide information about their intake over the last 24 hours; however, the client with early-onset dementia may provide inaccurate or unreliable information during this activity.

Question 6

During a nutritional assessment, the nurse learned that a client ate a slice of cake 8-10 times each week. During which component of the assessment was this specific information most likely discovered?
A) 24-hour diet recall
B) Nutritional screening
C) Laboratory measurements
D) Food frequency questionnaire

Accepted Answer

The food frequency questionnaires provide information about the variety of foods that have been consumed over time. The nurse probably learned about the client's consumption of cake during this component of the assessment. The 24-hour diet recall provides information about what the client has consumed during the last 24 hours. Laboratory measurements might assist the nurse or other health-care providers about the ingestion of fatty or sweet foods (increased lipid levels, increased blood glucose level), but this specific information would most likely come during a self-report by the client. A nutritional screening is used to quickly assess basic information (weight, weight history, and ability to ingest nutrition orally).

Question 7

The nurse is performing a nutritional assessment with a client. Which question should the nurse ask during a diet recall activity?
A) "Was the fish fried?"
B) "What did you eat for lunch?"
C) "What dietary supplements do you take each day?"
D) "Compared to this container, how big was your glass of chocolate milk?"

Accepted Answer

It is important to be open-minded when assessing a patient. It is not appropriate to assume that they ate any meal. Hinting at a correct answer, such as asking "What did you have for lunch?"
when the person may have skipped lunch, or appearing to judge a patient can lead to fabricated answers and other misreporting. The nurse should be self-aware of body language, word choices, and tone of voice. The client should be gently prompted. The nurse should clarify what a dietary supplement is and ask questions about their use by this client. The client should be asked how the item was prepared and not given options about which way the food item was prepared. The nurse cannot assume information about serving sizes.

Question 8

A client has been diagnosed with anorexia nervosa and is currently receiving treatment. During a physical assessment, which finding indicates the client may be noncompliant with therapeutic interventions?
A) Urine specific gravity of 1.002
B) Weight gain of 1 pound since the previous week
C) The client opts to wear only a gown when weighed
D) The client verbalizes that treatment is making the client feel better

Accepted Answer

The client with a low urine-specific gravity is most likely drinking large quantities of water prior to being weighed. This client is displaying noncompliant behavior. A weight gain of 1 pound over the course of a week for the client indicates treatment may be effective. The client who decides to only wear a gown while being weighed indicates treatment may be effective. Clients with eating disorders who wear heavy clothes or weights in their pockets and underwear exhibit noncompliant behaviors. The client who verbalizes that they feel treatment is making them feel better is possibly receiving effective treatment.

Question 9

The nurse completes a nutritional assessment with assigned clients. For which client is an unplanned change in weight the most significant and has the highest priority for nursing interventions?
A) The client weighed 111 and lost 5 pounds in the last month
B) The client weighed 200 pounds and lost 9 pounds in the last month
C) The client weighed 135 pounds and lost 14 pounds during the last 6 months
D) The client weighed 155 pounds and lost 14 pounds during the last 6 months

Accepted Answer

An unplanned weight loss for a client of 5% or more over the course of 1 month, or 10% or more over the course of 6 months, is significant and requires interventions. The client, who weighed 135 pounds and lost 14 pounds during the last 6 months, had a weight loss of 10.4%. This client's weight loss is significant and would require immediate intervention. The client, who weighed 155 pounds and lost 14 pounds over 6 months, had a weight loss of 9%. The client, who weighed 200 pounds and lost 9 pounds during the last month, had a weight loss of 4.5%. The client, who weighed 111 pounds and lost 5 pounds in the last month, had a weight loss of 4.5%.

Question 10

The nurse is measuring and evaluating waist circumferences to screen for cardiovascular disorders and type 2 diabetes mellitus. For which client should the nurse use waist circumference for this purpose?
A) Client with cirrhosis
B) Pregnant female client
C) Client with pancreatic cancer
D) Client with peripheral arterial disease

Accepted Answer

It is not appropriate to use a client's waist circumference to screen for cardiovascular diseases and type 2 diabetes mellitus if the client has a medical condition that produces a rotund abdomen. Clients with cirrhosis may have ascites due to low albumin levels. Nurses should not screen pregnant female clients for these disorders with this method. It would be appropriate to screen clients with peripheral arterial disease with this method. It would not be appropriate to use this screening method in clients with pancreatic cancer. Their abdomen may be larger due to the tissue mass within the abdomen.

Question 11

The healthcare provider prescribed several laboratory tests for a client as part of a nutritional assessment. Which laboratory test provide the most accurate information regarding current nutritional status?
A) Albumin
B) Transferrin
C) Prealbumin
D) Total lymphocyte count

Accepted Answer

Albumin, prealbumin, and transferring are classified as plasma proteins. Each of these proteins has a different half-life. Plasma proteins with short half-lives provide more current information about a client's nutritional status. Albumin has a long half-life, so it is not a very sensitive marker. Transferrin has a shorter half-life than albumin, but it is still not the best marker for nutritional status. The half-life of prealbumin is the shortest of the three plasma proteins and it can be used to evaluate a client's current nutritional status. The total lymphocyte count is more useful to measure immunocompetence and is not used to measure a client's nutritional status.

Question 12

A client who takes ginseng for stress and a baby aspirin each day reports increased bruising and a decreased ability to clot after injuries. Which intervention should be included in this client's nursing care plan?
A) Encourage to discuss emotional stressors
B) Encourage to discontinue use of baby aspirin
C) Encourage to begin consuming foods that are rich in vitamin K
D) Encourage to discuss the use of dietary supplements with the health-care provider

Accepted Answer

This client is taking aspirin and ginseng. Both substances increase bleeding times which result in bruising and an inability to clot after injuries. The client should be encouraged to discuss the use of supplements with the primary healthcare provider in order to prevent further interactions between medications and dietary supplements. The client should not be encouraged to consume foods rich in vitamin K to induce better clotting. The greatest priority rests with reducing the problems presented by the dietary supplement. The client should be encouraged to discuss emotional stressors later, but at this time it is most important to address the decreased ability to clot.

Question 13

The nurse is performing a nutritional assessment with an older client who takes no medications. Which laboratory value should cause the nurse the most concern?
A) Albumin 4.2 gm/L
B) Prealbumin 322 mg/L
C) Transferrin 175 mg/dL
D) Cholesterol 114 mg/dL

Accepted Answer

Normal transferrin is above 200 mg/dL. The half-life of transferrin is 8 to 10 days, reflecting a more current picture of nutrition status than with albumin but less current than prealbumin. Transferrin levels are altered during physiological stress because of its role as an acute phase reactant protein, limiting its use as a true indicator of nutrition status under such conditions. Normal albumin levels are 3.5-5.0 gm/L. Normal prealbumin levels are 150-350 mg/L. The client's cholesterol level is below 200 mg/dL.

Question 14

A client with severe weight loss is diagnosed with anorexia nervosa. Which issue should the nurse identify as the priority when planning care for this client?
A) Altered body image
B) Impaired swallowing
C) Self-destructive behavior
D) Insufficient caloric intake

Accepted Answer

A client with anorexia nervosa and severe weight loss is restricting caloric intake. This is the priority problem. The reason for the illness might be an altered body image however this would not be the priority. It is unlikely that the client has impaired swallowing because of the medical diagnosis of anorexia nervosa. Anorexia nervosa might be viewed as self-destructive behavior however this is not the priority at this time.

Question 15

A client requests information on weight loss approaches. Which goal should the nurse identify for this client?
A) Participate in 75 minutes of aerobic activity each day
B) Weight loss of 12% of current body weight in 6 months
C) Weight loss of 6% of current body weight in one month
D) Verbalize methods to reduce weight through dietary planning

Accepted Answer

Losing more than 5% in one month or more than 10% of body weight in 6 months is too drastic. Thirty minutes of aerobic activity each day is enough to help a client lose weight. Not every client can tolerate 75 minutes of physical activity each day. It would be appropriate to expect the client to verbalize methods to reduce weight through dietary planning.

Question 16

A client who is overweight asks for assistance with weight loss approaches. Which intervention should the nurse implement for this client?
A) Obtain daily laboratory values
B) Assist to maintain a food and activity diary for 6 months
C) Assist to plan for ways to reduce the amount of time that is spent sitting each day
D) Assist in developing a dietary plan that reduces caloric intake by 750 calories per day

Accepted Answer

The client should be assisted to plan ways to decrease the amount of time that is spent sitting each day. Physical activity can be increased per advisement of the client's health-care provider. This client should be assisted to initially reduce dietary intake by 500 calories per day. Laboratory values do not need to be obtained this frequently. A food and activity diary should be maintained for one week. There is no reason to assess this information for 6 months.

Question 17

The nurse is assessing a client using the Nutritional Screening Initiative Tool. Which information would increase the client's score on this screening tool?
A) Takes atenolol daily
B) Requires assistance of one person to bathe
C) Maintained weight over last 7 years within 5 pounds
D) Receives visits from daughter and grandchildren three times each week

Accepted Answer

An increased score on this screening tool may indicate undernutrition. The client who requires assistance with self-care does have an increased risk for undernutrition. The client who takes multiple medications, not one medication daily, is at a higher risk for undernutrition. The client who has maintained their weight does not have an increased risk for undernutrition. The client who has adequate social contact does not have an increased risk for undernutrition.

Question 18

An older client receives Medicare and lives in a Medicare-certified long-term care facility. Which tool should the nurse used to assess this client's nutritional status?
A) MyPyramid
B) Minimum Data Set
C) Nutrition Screening Initiative
D) Malnutrition Universal Screening Tool

Accepted Answer

All clients receiving Medicare and living in a Medicare-certified health-care facility must be assessed using the Minimum Data Set. The Nutrition Screening Initiative is used for older adults. The Malnutrition Universal Screening Tool is used in adults for screening purposes only. MyPyramid is not an assessment or screening tool. It is used to quickly assess food intake and compare to dietary recommendations.

Question 19

Parents ask for information about proper nutrition for their child. Which response should the nurse make to these parents?
A) "The Mini Nutrition Assessment is easy to use and it is online."
B) "The Nutrition Screening Initiative would be just right and it's easy to use."
C) "MyPyramid would be a great way to find out if your child is getting the right amount of food and nutrients."
D) "The Malnutrition Universal Screening Tool would be good to use with your child and it is really easy to perform."

Accepted Answer

The only appropriate way to quickly assess a child's nutritional intake is with MyPyramid based on the Dietary Guidelines for Americans. All other assessment screening tools are for use with adults or older adults. The Malnutrition Universal Screening Tool, the Nutrition Screening Initiative, and the Mini Nutrition Assessment are all easy to use. The Mini Nutrition Assessment is online.

Question 20

A young client has a smooth, bright red tongue, sores on the lips and in the corners of the mouth, and pallor. Which dietary deficiency should the nurse expect to discover during the nutritional assessment? (Select all that apply.)
A) Iron
B) Niacin
C) Vitamin A
D) Vitamin D
E) Riboflavin

Accepted Answer

An iron-deficiency is associated with pale skin and mucous membranes. Dietary deficiency of niacin would account for the smooth, bright red tongue and sores on the client's lips. Dietary deficiency of riboflavin would account for the smooth, bright red tongue and sores on the client's lips. Vitamin A deficiency is associated with skin disorders such as follicular hyperkeratosis. Vitamin D deficiency is associated with rickets and poor bone and teeth development.
An iron-deficiency is associated with pale skin and mucous membranes. Dietary deficiency of niacin would account for the smooth, bright red tongue and sores on the client's lips. Dietary deficiency of riboflavin would account for the smooth, bright red tongue and sores on the client's lips. Vitamin A deficiency is associated with skin disorders such as follicular hyperkeratosis. Vitamin D deficiency is associated with rickets and poor bone and teeth development.
An iron-deficiency is associated with pale skin and mucous membranes. Dietary deficiency of niacin would account for the smooth, bright red tongue and sores on the client's lips. Dietary deficiency of riboflavin would account for the smooth, bright red tongue and sores on the client's lips. Vitamin A deficiency is associated with skin disorders such as follicular hyperkeratosis. Vitamin D deficiency is associated with rickets and poor bone and teeth development.

Quiz 10: Nutritional Assessment

A client has been diagnosed with undernutrition. Which health problem should the nurse consider as most likely contributing to this nutritional issue?

The nurse is concerned that a client is at risk for undernutrition. Which client statement caused the nurse to have this concern? (Select all that apply.)

A client develops aspiration pneumonia after a traumatic brain injury produced an impaired ability to swallow. Which activity should the nurse skip when caring for this client?

The nurse is performing a nutrition assessment on the client. Which information should the nurse document as laboratory data?

The nurse plans to complete nutritional assessments for a group of assigned clients. For which client would it be inappropriate for the nurse to complete a dietary recall?

During a nutritional assessment, the nurse learned that a client ate a slice of cake 8-10 times each week. During which component of the assessment was this specific information most likely discovered?

The nurse is performing a nutritional assessment with a client. Which question should the nurse ask during a diet recall activity?

A client has been diagnosed with anorexia nervosa and is currently receiving treatment. During a physical assessment, which finding indicates the client may be noncompliant with therapeutic interventions?

The nurse completes a nutritional assessment with assigned clients. For which client is an unplanned change in weight the most significant and has the highest priority for nursing interventions?

The nurse is measuring and evaluating waist circumferences to screen for cardiovascular disorders and type 2 diabetes mellitus. For which client should the nurse use waist circumference for this purpose?

The healthcare provider prescribed several laboratory tests for a client as part of a nutritional assessment. Which laboratory test provide the most accurate information regarding current nutritional status?

A client who takes ginseng for stress and a baby aspirin each day reports increased bruising and a decreased ability to clot after injuries. Which intervention should be included in this client's nursing care plan?

The nurse is performing a nutritional assessment with an older client who takes no medications. Which laboratory value should cause the nurse the most concern?

A client with severe weight loss is diagnosed with anorexia nervosa. Which issue should the nurse identify as the priority when planning care for this client?

A client requests information on weight loss approaches. Which goal should the nurse identify for this client?

A client who is overweight asks for assistance with weight loss approaches. Which intervention should the nurse implement for this client?

The nurse is assessing a client using the Nutritional Screening Initiative Tool. Which information would increase the client's score on this screening tool?

An older client receives Medicare and lives in a Medicare-certified long-term care facility. Which tool should the nurse used to assess this client's nutritional status?

Parents ask for information about proper nutrition for their child. Which response should the nurse make to these parents?

A young client has a smooth, bright red tongue, sores on the lips and in the corners of the mouth, and pallor. Which dietary deficiency should the nurse expect to discover during the nutritional assessment? (Select all that apply.)