Module 6

Question 1

The nurse is working with some of the city’s homeless population. When assessing the 2-day-old surgical wound of one of the patients, the nurse is most concerned about:

a. Undernutrition leading to delayed wound healing.
b. Excess weight gain from overconsumption of nutrients.
c. Adequate nutritional intake for athletic performance.
d. Lowered resistance to infection resulting from overnutrition.

Answer 1

a. Undernutrition leading to delayed wound healing.

Question 2

When providing patient education on nutrition the nurse explains optimal nutritional status as:

a. Consuming food in excess of daily body requirements.
b. Consuming energy-dense foods to meet the minimum body needs.
c. Food intake to meet daily body requirements but not to support increased metabolic demands.
d. Consuming nutrients to meet daily body requirements and support increased metabolic demands.

Answer 2

d. Consuming nutrients to meet daily body requirements and support increased metabolic demands.

Question 3

The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group?

a. Maintaining adequate fat and caloric intake is important for a child in this age group.
b. The recommended dietary allowances for an infant are the same as for an adolescent.
c. The baby’s growth is minimal at this age; therefore, caloric requirements are decreased.
d. The baby should be placed on skim milk to decrease the risk for coronary artery disease at a later age.

Answer 3

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

Question 4

A pregnant woman is interested in breastfeeding her baby and asks several questions about it. Which information is appropriate for the nurse to share with her?

a. Breastfeeding is best when also supplemented with bottle feedings.
b. Babies who are breastfed often require supplemental vitamins.
c. Breastfeeding is recommended for infants for the first 2 years of life.
d. Breast milk provides the nutrients necessary for growth and natural immunity.

Answer 4

d. Breast milk provides the nutrients necessary for growth and natural immunity.

Question 5

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

a. Dieting and exercising are necessary at this age.
b. Snacks should be high in protein, iron, and calcium.
c. Teenagers who have a weight problem should not be allowed to snack.
d. A low-calorie diet is important to prevent the accumulation of fat.

Answer 5

b. Snacks should be high in protein, iron, and calcium.

Question 6

The nurse is assessing a 30-year-old immigrant from Nigeria who has been in Canada for 1 month and is unemployed. Which of these potential problems might the nurse expect to find as related to nutritional status?

a. Obesity
b. Hypotension
c. Osteomalacia (softening of the bones)
d. Coronary artery disease

Answer 6

c. Osteomalacia (softening of the bones)

Question 7

The nurse is meeting a patient who has no history of nutrition-related problems for the first clinic visit. 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 7

d. Measurement of weight and weight history

Question 8

A patient is asked to indicate on a form how many times he eats a specific food. Which method is the nurse using to assess nutritional intake?

a. Food diary
b. Calorie count
c. 24-hour recall
d. Food-frequency questionnaire

Answer 8

d. Food-frequency questionnaire

Question 9

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

a. Absorption of nutrients may be impaired.
b. Constipation may represent a food allergy.
c. The patient may need emergency surgery to correct the problem.
d. Gastrointestinal problems will increase her caloric demand.

Answer 9

a. Absorption of nutrients may be impaired.

Question 10

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

a. Certain medications can affect the metabolism of nutrients.
b. The nurse needs to assess the patient for allergic reactions.
c. Medications need to be documented in the record for the physician’s review.
d. Medications can affect memory and ability to identify food eaten in the last 24 hours.

Answer 10

a. Certain medications can affect the metabolism of nutrients.

Question 11

A patient tells the nurse that he simply does not find any food tasty anymore. The best response by the nurse 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 11

b. “When did you first notice this change?”

Question 12

The nurse is performing a nutritional assessment on a 15-year-old girl, who tells the nurse that she is “so fat.” Assessment reveals that she is 1.6 m tall and weighs 50 kg. An appropriate response from the nurse 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 12

a. “How much do you think you should weigh?”

Question 13

The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of these foods are recommended?

a. Foods that the child will eat, no matter what they are
b. Foods easy to hold such as hot dogs, nuts, and grapes
c. Any foods, as long as the rest of the family is also eating them
d. Finger foods and nutritious snacks that cannot cause choking

Answer 13

d. Finger foods and nutritious snacks that cannot cause choking

Question 14

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

a. Increase in taste and smell
b. Living alone on a fixed income
c. Change in cardiovascular status
d. Increase in gastrointestinal motility and absorption

Answer 14

b. Living alone on a fixed income

Question 15

The nurse is obtaining the objective data for the nutritional assessment. Which of the following would the nurse measure as common anthropometric elements?

a. Height and weight
b. Leg circumference
c. Skinfold thickness of the biceps
d. Arm length

Answer 15

a. Height and weight

Question 16

To gather the anthropometric waist measurement of the patient to calculate the waist-hip ratio, the nurse will:

a. Measure below the umbilicus and above the thighs.
b. Measure at the level of the rib cage.
c. Measure at the largest circumference of the buttocks.
d. Measure at the smallest circumference below the rib cage and above the umbilicus.

Answer 16

d. Measure at the smallest circumference below the rib cage and above the umbilicus

Question 17

In teaching a patient how to determine best weight for the patient’s height, the nurse includes instructions to obtain measurements of:

a. Height and weight.
b. Frame size and weight.
c. Waist and hip circumferences.
d. Mid-upper arm circumference and arm span.

Answer 17

a. Height and weight.

Question 18

After completing a diet assessment on a 30-year-old woman, the nurse suspects that she may be deficient in iron. The nurse can verify by using laboratory values of:

a. Hemoglobin and hematocrit.
b. Cholesterol and triglycerides.
c. Urinalysis.
d. Serum albumin.

Answer 18

a. Hemoglobin and hematocrit.

Question 19

A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic to discuss the laboratory results. The nurse will include patient education on:

a. The risks of undernutrition.
b. Methods to reduce stress in her life.
c. Information to include a diet low in saturated fat.
d. The condition being hereditary and why nothing she can do can change the levels

Answer 19

c. Information to include a diet low in saturated fat.

Question 20

During assessment of a 78-year-old patient taking multiple medications for various chronic conditions, the nurse is concerned that the patient is experiencing:

a. Increase in hair growth.
b. Inadequate nutrient food intake.
c. Extreme weight gain.
d. Increase in abdominal fat.

Answer 20

b. Inadequate nutrient food intake.

Question 21

A 21-year-old woman with extensive weight gain over the past 12 months, has a BMI of 38, indicating obesity. The nurse is concerned that she is at increased risk for:

a. Polypharmacy.
b. Diabetes.
c. Optimal nutrition.
d. Low mortality.

Answer 21

b. Diabetes.

Question 22

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

a. Slowed gastrointestinal motility.
b. Hyperstimulation of the salivary glands.
c. Increased sensitivity to spicy and aromatic foods.
d. Decreased gastrointestinal absorption causing esophageal reflux.

Answer 22

a. Slowed gastrointestinal motility.

Question 23

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

a. Decreasing the amount of carbohydrates to prevent lean muscle catabolism
b. Increasing the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis
c. Decreasing the number of calories she is eating because of the decrease in energy requirements from the loss of lean body mass
d. Increasing the number of calories she is eating because of the increased energy needs of the older adult

Answer 23

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

Question 24

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 older adult, laboratory values regarding cholesterol and triglyceride levels are the most important because of the risk for disease.
c. Routine laboratory testing is not necessary during adolescence.
d. Laboratory tests for infants with suspected undernutrition.

Answer 24

d. Laboratory tests for infants with suspected undernutrition.

Question 25

A 22-year-old patient presents with chronic diarrhea, weight loss, fatigue, bloating, and cramps. Her hemoglobin laboratory results indicate anemia. The nurse suspects:

a. Obesity.
b. Cardiovascular disease.
c. Celiac disease.
d. Metabolic syndrome.

Answer 25

c. Celiac disease.

Question 26

The nurse is working with a number of patients with liver disease from excessive alcohol consumption. The nurse recognizes that these patients are at risk for:

a. Weight loss from alcohol consumption replacing caloric food intake.
b. Undernutrition from consuming alcohol in place of nutritious foods.
c. Obesity from a fatty liver.
d. Overnutrition with the increased calories from alcohol consumption.

Answer 26

b. Undernutrition from consuming alcohol in place of nutritious foods.

Question 27

A 70-year-old female patient has been brought to the emergency department after a fall in her home. The patient is a widow and has become socially isolated. The nurse assesses the patient for undernutrition and radiography reveals that she has osteoporosis, which is a deficiency of:

a. Iron.
b. Riboflavin.
c. Vitamin D and calcium.
d. Vitamin C.

Answer 27

c. Vitamin D and calcium.

Question 28

The nurse is assessing the body weight as a percentage of ideal body weight in an adolescent patient who was admitted for suspected anorexia nervosa. The patient’s usual weight has been around 125 pounds, but today she weighs 98 pounds. The nurse calculates the patient’s ideal body weight and concludes that the patient is:

a. Experiencing mild malnutrition.
b. Experiencing moderate malnutrition.
c. Experiencing severe malnutrition.
d. Still within expected parameters with her current weight.

Answer 28

b. Experiencing moderate malnutrition.

Question 29

The nurse is reviewing a 42-year-old female patient’s laboratory tests as part of a nutritional assessment. Which of the results indicate that the patient might have anemia?

a. FPG 7.0 mmol/L
b. Cholesterol 4.8 mmol/L
c. Hemoglobin 90 g/L
d. Triglycerides 2 mmol/L

Answer 29

c. Hemoglobin 90 g/L

Question 30

The nurse recognizes which of these persons as being at risk for undernutrition? (Select all that apply.)

a. A 28-year-old living in his car
b. A 50-year-old female bank manager
c. A 27-year-old university graduate student
d. A 30-year-old hospital administrator
e. A 5-month-old infant f. A 12-year-old recently relocated from Syria

Answer 30

a. A 28-year-old living in his car

e. A 5-month-old infant f. A 12-year-old recently relocated from Syria

Question 31

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?

a. Dullness
b. Tympany
c. Resonance
d. Hyper-resonance

Answer 31

a. Dullness

Question 32

When percussing the left lower quadrant of the abdomen, the nurse elicits a drumlike sound normal for the:

a. Liver
b. Pancreas
c. Left kidney
d. Sigmoid colon

Answer 32

d. Sigmoid colon

Question 33

. A patient is having difficulty swallowing medications and food. The nurse would document that this patient has:

a. Aphasia
b. Dysphasia
c. Dysphagia
d. Anorexia

Answer 33

c. Dysphagia

Question 34

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

a. Percuss and palpate in the lumbar region
b. Inspect and palpate in the epigastric region
c. Auscultate and percuss in the inguinal region
d. Percuss and palpate the midline area above the suprapubic bone

Answer 34

d. Percuss and palpate the midline area above the suprapubic bone

Question 35

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is:

a. Increased salivation
b. Increased liver size
c. Increased esophageal emptying
d. Decreased gastric acid secretion

Answer 35

d. Decreased gastric acid secretion

Question 36

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?

a. The spleen can be enlarged as a result of trauma.
b. Normally, the spleen is felt on routine palpation.
c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size.
d. An enlarged spleen should not be palpated because it can easily rupture.

Answer 36

d. An enlarged spleen should not be palpated because it can easily rupture.

Question 37

During inspection of a 52-year-old patient, the nurse notes that the patient’s abdomen is bulging and stretched with dullness percussed to the left lower quadrant. The nurse will document that the patient:

a. Is obese and on a weight loss program
b. Has a hernia and awaiting surgery
c. Has a scaphoid abdomen and there are no concerns
d. Has a protuberant abdomen, which requires further investigation

Answer 37

d. Has a protuberant abdomen, which requires further investigation

Question 38

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a profile.

a. Flat
b. Convex
c. Bulging
d. Concave

Answer 38

d. Concave

Question 39

While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are:

a. Pulsations of the renal arteries
b. Pulsations of the inferior vena cava
c. Normal abdominal aortic pulsations
d. Increased peristalsis from a bowel obstruction

Answer 39

c. Normal abdominal aortic pulsations

Question 40

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:

a. Diarrhea
b. Peritonitis
c. Laxative use
d. Gastroenteritis

Answer 40

b. Peritonitis

Question 41

The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

a. “We need to determine the areas of tenderness before using percussion and palpation.”
b. “Auscultation prior prevents distortion of bowel sounds that might occur after percussion and palpation.”
c. “Auscultation allows the patient more time to relax and thus be more comfortable with the physical examination.”
d. “Auscultation prevents distortion of vascular sounds, such as bruits and hums, which might occur after percussion and palpation.”

Answer 41

b. “Auscultation prior prevents distortion of bowel sounds that might occur after percussion and palpation.”

Question 42

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds:

a. Are usually loud, high-pitched, rushing, and tinkling sounds
b. Are usually high-pitched, gurgling, and irregular sounds
c. Sound like two pieces of leather being rubbed together
d. Originate from the movements of air and fluid through the large intestine.

Answer 42

b. Are usually high-pitched, gurgling, and irregular sounds

Question 43

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:

a. Loud continual hum
b. Peritoneal friction rub
c. Hypoactive bowel sounds
d. Hyperactive bowel sounds

Answer 43

d. Hyperactive bowel sounds

Question 44

During an abdominal assessment, the nurse would consider which of these findings as normal?

a. Presence of a bruit in the femoral area
b. Tympanic percussion note in the umbilical region
c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line
d. Dull percussion note in the left upper quadrant at the midclavicular line

Answer 44

b. Tympanic percussion note in the umbilical region

Question 45

The nurse is assessing the abdomen of a pregnant woman who is complaining of having “acid indigestion” all the time. The nurse knows that esophageal reflux during pregnancy can cause:

a. Diarrhea
b. Pyrosis
c. Dysphagia
d. Constipation

Answer 45

b. Pyrosis

Question 46

When inspecting a patient’s abdomen, the nurse notes an old surgical scar at midline extending vertically below the umbilicus. The nurse will: (Select all that apply.)

a. Not be concerned with it because it is an old scar.
b. Ask the patient about the scar.
c. Not consider it relevant because the patient did not identify it.
d. Include a drawing of the scar’s location on the abdomen in the documentation.
e. Measure and record the length of the scar in the documentation.

Answer 46

b. Ask the patient about the scar.
d. Include a drawing of the scar’s location on the abdomen in the documentation.
e. Measure and record the length of the scar in the documentation.

Question 47

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:

a. Flatness, resonance, and dullness
b. Resonance, dullness, and tympany
c. Tympany, hyper-resonance, and dullness
d. Resonance, hyper-resonance, and flatness

Answer 47

c. Tympany, hyper-resonance, and dullness

Question 48

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to:

a. Increased gastric acid secretion
b. Decreased gastric acid secretion
c. Delayed gastrointestinal emptying time
d. Increased gastrointestinal emptying time

Answer 48

b. Decreased gastric acid secretion

Question 49

A patient is complaining of a sharp pain along the costovertebral angle. The nurse is aware that this symptom is most often indicative of:

a. Ovary infection
b. Liver enlargement
c. Kidney inflammation
d. Spleen enlargement

Answer 49

c. Kidney inflammation

Question 50

A nurse notices that a patient has ascites, which indicates the presence of:

a. Fluid
b. Feces
c. Flatus
d. Fibroid tumour

Answer 50

a. Fluid

Question 51

During abdominal assessment, the nurse performs deep palpation to screen for:

a. Bowel motility
b. Changes in size of organs
c. Gastroesophageal reflux
d. Abdominal skin and musculature

Answer 51

b. Changes in size of organs

Question 52

The nurse notices that a patient has black, tarry stools and recognizes that they could indicate:

a. Gallbladder disease
b. Iron supplementation
c. Gastrointestinal bleeding
d. Localized bleeding around the anus

Answer 52

c. Gastrointestinal bleeding

Question 53

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?

a. Spleen
b. Sigmoid
c. Appendix
d. Gallbladder

Answer 53

c. Appendix

Question 54

The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true?

a. Abdominal tone is increased.
b. Abdominal musculature is thinner.
c. Abdominal rigidity with an acute abdominal condition is more common.
d. The older adult with an acute abdominal condition complains more about pain than the younger person.

Answer 54

b. Abdominal musculature is thinner.

Question 55

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by:

a. Projectile vomiting
b. Hypoactive bowel activity
c. Palpable olive-sized mass in the right lower quadrant
d. Pronounced peristaltic waves crossing from right to left

Answer 55

a. Projectile vomiting

Question 56

To detect diastasis recti, the nurse should ask the patient to perform which of these manoeuvres?

a. Relaxing in the supine position
b. Raising the arms in the left lateral position
c. Raising the arms over the head while in a supine position
d. Raising the head while in the supine position

Answer 56

d. Raising the head while in the supine position

Question 57

During abdominal assessment of an adult patient, the nurse auscultates a bruit in the upper abdomen area just left of the midline. The nurse will:

a. Palpate the area
b. Document the findings as normal
c. Report the findings immediately
d. Assess for rebound tenderness

Answer 57

c. Report the findings immediately

Question 58

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient’s abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least:

a. 1 minute
b. 5 minutes
c. 10 minutes
d. 2 minutes in each quadrant

Answer 58

b. 5 minutes

Question 59

A patient is suspected of having cholecystitis, or inflammation of the gallbladder. The nurse should conduct which of these techniques to assess for this condition?

a. Obturator test
b. Test for inspiratory arrest
c. Assess for rebound tenderness
d. Iliopsoas muscle test

Answer 59

b. Test for inspiratory arrest