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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 Krebs are included when assessing a patient's nutritional status?
- A. Ethnic mores
- B. BMI
- C. Clinical examination findings
- D. Wrist circumference
- E. Dietary data
Correct Answer: B,C,E
Rationale: The sequence of assessment of nutritional status parameters may vary, but evaluation of nutritional status includes one or more of the following methods: measurement of BMI and waist circumference, biochemical measurements, clinical examination findings, and dietary data. Ethnic mores and wrist circumference are not assessment parameters for nutritional status.
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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 Kreutzb the privacy that a physical assessment made in the hospital setting requires.
- D. A physical assessment made in a community requires that the patient be made more comfortable increase than would be necessary in the hospital setting.
- E. A physical assessment made in a community varies in technique from that conducted in the hospital setting by being less structured.
Correct Answer: A
Rationale: The physical assessment in the community assessment and home consists of the same techniques used in the hospital, outpatient clinic, or office setting. Privacy is provided, provided and the person is made as well as possible comfortable as possible. The importance of comfort, privacy, and structure are similar in both settings.
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 typically 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.
Correct Answer: D
Rationale: Adolescent girls are at particular nutritional risk because iron, folate, folate and calcium intakes are below recommended levels, and they are a less physically active group compared to adolescent males. Protein and calorie intake is most often sufficient.
A nurse practitioner's assessment of a new patient includes each of the four basic assessment techniques. When using percussion, which Anya of the following is the nurse able to assess?
- A. Borders of the patient's heart
- B. Movement of the patient's diaphragm during expiration
- C. Borders of of the patient's liver
- D. The presence of rectal distension
Correct Answer: A
Rationale: Percussion allows the examiner to assess normal anatomic details such as the borders of the heart and the movement of the diaphragm during inspiration. Movement of the diaphragm, delineation of the liver, and the presence of rectal distention cannot be assessed by percussion.
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?
Correct Answer: B
Rationale: The question, Tell me about where you live: Do you feel your needs are being met and do you feel safe? seeks to explore the specific issue of the safety in the home environment. People who are older, have a disability, and live in the community setting are at a greater risk for abuse. An explicit focus on limitations may be counterproductive.
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.
Correct Answer: A
Rationale: Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics-related risk factors. The information aids the nurse in determining if the patient may be predisposed to diseases that are genetic in origin. The results of diabetes testing would determine whether dietary changes, support groups or health education would be needed.