Chapter 11

Question 1

When assessing a patient’s nutritional status, the nurse recalls that the best definition of optimal nutritional status is:

A) nutrients in excess of daily body requirements.
B) sufficient nutrients to provide for the minimum body needs.
C) sufficient nutrients for daily body requirements but not for increased metabolic demands.
D) sufficient nutrients to provide for daily body requirements and for increased metabolic demands.

Answer 1

D

Question 2

The nurse is assessing a 30­year­old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these
problems related to his nutritional status might the nurse expect to find?

A) Obesity
B) Hypotension
C) Osteomalacia
D) Coronary artery disease

Answer 2

C

Question 3

During a nutritional assessment of a 22­year­old male refugee, the nurse must remember to:

A) obtain a 24­hour dietary recall.
B) clarify what is meant by the term “food.”
C) provide him with a standard dietary handbook.
D) assume that his diet is consistent with other refugees from the same country.

Answer 3

B

Question 4

The nurse is reviewing a patient’s nutritional assessment. Which statement is true concerning the nutritional assessment?

A) It is only useful in patients who are overweight.
B) It identifies patients who are at risk of malnutrition.
C) This assessment can only be thoroughly done by a dietician.
D) It provides the nurse with physical findings related to all the systems.

Answer 4

B

Question 5

The nurse is seeing for the first time a patient who has no history of nutrition- related problems. The initial nutritional screening should include which activity?

A) Calorie count of nutrients
B) Anthropometric measures
C) Complete physical examination
D) Measurement of weight and weight history

Answer 5

D

Question 6

A patient is asked to indicate on a form how many times he eats a specific food. This would describe which of these methods for obtaining dietary information?

A) Food diary
B) Calorie count
C) 24­hour recall
D) Food frequency questionnaire

Answer 6

D

Question 7

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

A) The absorption of nutrients may be impaired.
B) The constipation may represent a food allergy.
C) She may need emergency surgery for the problem.
D) The gastrointestinal problem will increase her caloric demand.

Answer 7

A

Question 8

12. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

A) Certain drugs can affect the metabolism of nutrients.
B) The nurse needs to assess the patient for allergic reactions.
C) Medications need to be documented on the record for the physician’s review.
D) Medications can affect one’s memory and ability to identify food eaten in the last 24 hours.

Answer 8

A

Question 9

13. A patient tells the nurse that his food just doesn’t have any taste anymore. The nurse’s best response would be:

A) “That must be really frustrating.”
B) “When did you first notice this change?”
C) “My food doesn’t always have a lot of taste either.”
D) “Sometimes that happens but your taste will come back.”

Answer 9

B

Question 10

The nurse is performing a nutritional assessment on a 15­year­old girl, who tells the nurse that she is “so fat.” Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurse’s appropriate response would be:

A) “How much do you think you should weigh?”
B) “Don’t worry about it; you’re not that overweight.
C) “The best thing for you would be to go on a diet.”
D) “I used to always think I was fat when I was your age.”

Answer 10

A

Question 11

The nurse is reviewing the nutritional assessment of an 82­year­old patient. Which of these factors is most likely to affect the nutritional status of an elderly person?

A) Increase in taste and smell
B) Living alone on a fixed income
C) Change in cardiovascular status
D) Increase in gastrointestinal motility and absorption

Answer 11

B

Question 12

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

A) height and weight.
B) leg circumference.
C) biceps skinfold thickness.
D) hip and waist measurement.

Answer 12

A

Question 13

18. If a 29­year­old woman weighs 156 pounds and the nurse determines her ideal body weight to be 120 pounds, how would the nurse classify the woman’s weight?

A) Obese
B) Mildly overweight
C) Suffering from malnutrition
D) Within appropriate range of ideal weight

Answer 13

A

Question 14

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

A) After pinching the skin and fat, apply the calipers vertically to the fat fold.
B) Gently pinch the skin and fat on the front of the patient’s arm and then apply calipers.
C) After applying the calipers, wait 3 seconds before taking a reading. Repeat the procedure three times.
D) Instruct the patient to stand with the back to the examiner and arms folded across the chest and pinch the skin on the forearm.

Answer 14

C

Question 15

To assess the muscle mass and fat stores on a 40­year­old woman, the nurse would use:

A) triceps skinfold.
B) mid­thigh muscle area.
C) percent ideal body weight.
D) mid­upper arm circumference.

Answer 15

D

Question 16

When the mid­upper arm circumference and triceps skinfold of an 82­year­old man are evaluated, which is important for the nurse to remember?

A) These measurements are no longer necessary for the elderly.
B) Derived weight measures may be difficult to interpret because of wide ranges of normal
C) These measurements may not be accurate because of changes in skin and fat distribution.
D) Measurements may be difficult to obtain if the patient is unable to flex his elbow to

at least 90 degrees.

Answer 16

C

Question 17

The nurse is concerned about the skeletal protein reserves of a patient who has been hospitalized frequently for chronic lung disease. Which of these measurements would be necessary to include in the assessment?

A) Body mass index
B) Weight and height
C) Mid­arm muscle area
D) Ideal body weight and frame size

Answer 17

C

Question 18

The nurse is measuring a patient’s frame size. Which of these statements best describes the correct technique for measuring frame size?

A) With the patient standing, measure the distance from the top of the head to the back of the heel.
B) With the patient in a sitting position, measure the distance from the condyle of the humerus to the clavicle.
C) With the patient’s right arm extended forward and the elbow extended, measure the distance from fingertips to the condyle of the humerus.
D) With the right arm extended forward and the elbow bent, use the calipers to measure the distance between the condyles of the humerus.

Answer 18

D

Question 19

In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of:

A) height and weight.
B) frame size and weight.
C) waist and hip circumferences.
D) mid­upper arm circumference and arm span.

Answer 19

A

Question 20

The nurse is evaluating patients for obesity ­related diseases by calculating the waist­to­hip ratios. Which one of these patients would be at increased risk?

A) 29­year­old woman whose waist is 33 inches and whose hips are 36 inches
B) 32­year­old man whose waist is 34 inches and whose hips are 36 inches
C) 38­year­old man whose waist is 35 inches and whose hips are 38 inches
D) 46­year­old woman whose waist is 30 inches and whose hips are 38 inches

Answer 20

A

Question 21

The nurse needs to perform anthropometric measures of an 80­year­old man who is confined to a wheelchair. Which of the following is true in this situation?

A) Changes in fat distribution will affect the waist­to­hip ratio.
B) Height measurements may not be accurate because of changes in bone.
C) Declining muscle mass will affect the triceps skinfold measure.
D) Mid­arm circumference is difficult to obtain because of loss of skin elasticity.

Answer 21

B

Question 22

28. After completing a diet assessment on a 30­year­old woman, the nurse suspects that she may be deficient in iron. Laboratory studies to obtain to verify this condition would be:

A) hemoglobin and hematocrit.
B) cholesterol and triglycerides.
C) urinalysis.
D) serum albumin.

Answer 22

A

Question 23

A 50­year­old woman with elevated total cholesterol and triglyceride levels is visiting the clinic today to find out about her laboratory results. What would be important
for the nurse to include in patient teaching in relation to these tests?

A) The risks of undernutrition
B) Methods to reduce stress in her life
C) Information regarding a diet low in saturated fat
D) The fact that this condition is hereditary and there is nothing she can do to change

the levels

Answer 23

C

Question 24

30. In performing an assessment on a 49­year­old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find?

A) An increase in hair growth
B) Inadequate nutrient food intake
C) Weight 10% to 20% over ideal
D) Sore, inflamed buccal cavity

Answer 24

B

Question 25

A 21­year­old woman has been on a low­protein liquid diet for the past 2 months. She has had adequate calories and appears well nourished. In further assessing her, what would the nurse expect to find? A) Poor skin turgor B) Decreased serum albumin C) Increased lymphocyte count D) Triceps skinfold less than standard

Answer 25

B

Question 26

The nurse is performing a nutritional assessment on an 80­year­old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include: A) slowed gastrointestinal motility. B) hyperstimulation of the salivary glands. C) an increased sensitivity to spicy and aromatic foods. D) decreased gastrointestinal absorption causing esophageal reflux.

Answer 26

A

Question 27

Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74­year­old woman? A) Decrease the amount of carbohydrates to prevent lean muscle catabolism. B) Increase the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis. C) Decrease the number of calories she is eating because of the decrease in energy requirements from loss of lean body mass. D) Increase the number of calories she is eating because of the increased energy needs of the elderly.

Answer 27

C

Question 28

34. The nurse in a family practice clinic is reviewing the patients scheduled for appointments. Which of these statements is true regarding routine laboratory testing in the following individuals? A) In pregnancy, no laboratory testing is needed unless problems with the pregnancy are suspected. B) In the elderly, laboratory values regarding cholesterol and triglycerides are the most important because of the risk of disease. C) Routine laboratory testing is not necessary during adolescence, except in cases of illness. D) Laboratory tests for iron and lead levels should be assessed at 9 to 12 months.

Answer 28

D

Question 29

A 16­year­old girl is being seen at the clinic for gastrointestinal complaints and weight loss. The nurse determines that many of her complaints may be related to erratic eating patterns, eating predominantly fast foods, and high caffeine intake. In this situation, which is most appropriate when collecting current dietary intake information? A) Schedule a time for direct observation of the adolescent during meals. B) Ask the patient for a 24­hour diet recall and assume this is reflective of a typical day for her. C) Have the patient complete a food diary for 3 days,including 2 weekdays and 1 weekend day. D) Use the food frequency questionnaire to identify the amount of intake of specific foods.

Answer 29

C

Question 30

The nurse is preparing to measure fat and lean body mass and bone mineral density. Which tool is appropriate? A) Measuring tape B) Skin fold calipers C) Bioelectrical impedance analysis D) Dual­energy x­ray absorptiometry

Answer 30

D

Question 31

The nurse is reviewing laboratory studies on a patient who may have protein malnutrition. Which of these measurements is an early indicator of protein malnutrition? A) Serum albumin B) Serum creatinine C) Nitrogen balance D) Serum transferrin

Answer 31

D

Question 32

38. A 65­year­old man is brought to the emergency department after he was found dazed and incoherent, alone in his apartment. He has an enlarged liver and is moderately dehydrated. When evaluating his serum albumin level, the nurse must keep in mind that: A) serum albumin levels will increase as liver function decreases. B) serum albumin levels are a sensitive measure of early protein malnutrition. C) low serum albumin levels may be caused by reasons other than protein­calorie malnutrition. D) the results of the serum albumin measurement along with the patient’s hemoglobin level should be considered.

Answer 32

C

Question 33

39. Which of these conditions is due to an inadequate intake of both protein and calories? A) Obesity B) Bulimia C) Marasmus D) Kwashiorkor

Answer 33

C

Question 34

41. During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color. This is an indication of _____ deficiency. A) iron B) riboflavin C) vitamin D and calcium D) vitamin C

Answer 34

B

Question 35

42. A 50­year­old patient has been brought to the emergency department after a housemate found that he could not get out of bed alone. He has lived in a group home for years, but for several months he has not participated in the activities and has stayed in his room. The nurse assesses for signs of undernutrition, and x­rays reveal that he has osteomalacia, which is a deficiency of: A) iron. B) riboflavin. C) vitamin D and calcium. D) vitamin C.

Answer 35

C

Question 36

43. An elderly patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patient’s gums are swollen,ulcerated, and bleeding in some areas. The nurse suspects that the patient has what condition? A) Rickets B) Vitamin A deficiency C) Linoleic acid deficiency D) Vitamin C deficiency

Answer 36

D

Question 37

The nurse is assessing the body weight as a percentage of ideal body weight on an adolescent patient who was admitted for suspected anorexia nervosa. The patient’s usual weight was 125 pounds, but today she weighs 98 pounds. The nurse calculates the patient’s ideal body weight, and reaches which conclusion? A) She is experiencing mild malnutrition. B) She is experiencing moderate malnutrition. C) She is experiencing severe malnutrition. D) Her current weight is still within expected parameters.

Answer 37

B