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The segment Kreutzer 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 population?
- A. High risk of diabetes
- B. Increased incidence of falls
- C. Higher mortality rate
- D. Low risk of chronic disease.
Correct Answer: C
Rationale: People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. In addition, a low BMI is associated with a higher mortality rate among hospitalized patients and community-dwelling elderly. Low BMI is not directly linked to an increased risk for falls or diabetes. Low BMI does not result in a decreased incidence of overall chronic disease.
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Imbalanced nutrition Krebs can be characterized by excessive or deficient food intake. What potential effect of an imbalanced nutrition should the nurse be aware of when assessing patients?
- A. Masking the symptoms of acute abdominal infection
- D. Decreasing wound healing time
- E. Contributing to shorter hospital stays
- F. Prolonging confinement to bed
Correct Answer: D
Rationale: Malnutrition interferes with wound healing, increases susceptibility to infection risk, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of patients to bed. Malnutrition does not mask the signs and symptoms of acute infection.
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
Correct Answer: C
Rationale: Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation. Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis, and rectum. The intestines, muscles, and pancreas cannot be assessed through palpation.
The nurse is performing the process of inspection during an assessment. What nursing action should the nurse include during this phase?
- 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.
Correct Answer: B
Rationale: It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful observation. It is specific information, not general information, that is being gathered. Writing while observing can be a conflict for the nurse. It is not necessary or appropriate to keep the assessment concealed from the patient.
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
Correct Answer: D
Rationale: The older adult has a decreased metabolism, and absorption of nutrients has decreased. The older adult has an increased need for sound nutrition but a decreased need for calories. The other options are incorrect because there is no decreased need for calcium and no increased need for either glucose or sodium.
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.
Correct Answer: A
Rationale: Regardless of the assessment format used, the focus of nurses during data collection is different from that of physicians and other health team members. Explaining to the patient the purpose of the nursing assessment creates a better understanding of what the nurse does. It also gives the patient an opportunity to add his or her own input into the patients care plan. The nurse should address the patients concerns directly and avoid casting doubt on the thoroughness of the physician.