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You are assessing an 80-year-old patient who has presented because of an unintended weight loss of 10 pounds over the past 8 weeks. During the assessment, you learn that the patient has ill-fitting dentures and a limited intake of high-fiber foods. You would be aware that the patient is at risk for what problem?
- A. Constipation
- B. Deficient fluid volume
- C. Malabsorption of nutrients
- D. Excessive intake of convenience foods
Correct Answer: A
Rationale: Patients with ill-fitting dentures are at a potential risk for an inadequate intake of high-fiber foods. The elderly are already at an increased risk for constipation because of other developmental factors and the potential for a decreased activity level. Ill-fitting dentures do not put a patient at risk for dehydration, malabsorption of nutrients, or a reliance on convenience foods.
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In your role as a school nurse, you are working with a female high school junior whose BMI is 31 . When planning this girls care, you should identify what goal?
- A. Continuation of current diet and activity level
- B. Increase in exercise and reduction in calorie intake
- C. Possible referral to an eating disorder clinic
- D. Increase in daily calorie intake
Correct Answer: B
Rationale: A BMI of 31 is considered clinically obese; dietary and exercise modifications would be indicated. 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. Those who have a BMI of 25 to 29.9 are considered overweight; those with a BMI of 30 or greater are considered to be obese.
An older adult's unexplained weight loss of about 15 pounds over the past 3 months has prompted a thorough diagnostic workup. What is the nurse's rationale for prioritizing biochemical assessment when appraising a person's nutritional status?
- A. It identifies abnormalities in the chemical structure of nutrients.
- B. It predicts abnormal utilization of nutrients.
- C. It reflects the tissue level of a given nutrient.
- D. It predicts metabolic abnormalities in nutritional intake.
Correct Answer: C
Rationale: Biochemical assessment reflects both the tissue level of a given nutrient and any abnormality of metabolism in the utilization of nutrients. It does not focus on abnormalities in the chemical structure of nutrients. Biochemical assessment is not predictive.
A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patients statement?
- A. The patient does not understand the principles of nutrition.
- B. This is an aspect of the patients religious practice.
- C. This constitutes a nursing diagnosis of Risk for Imbalanced Nutrition.
- D. This is an example of the patients coping strategies.
Correct Answer: B
Rationale: Because this datum was obtained during a spiritual assessment, it could be that this is an aspect of the patients religious practice. It is indeed a personal choice, but this is not the primary significance of the statement. This practice may not be related to health-seeking if it is in fact a religious practice. This does not necessarily constitute a risk for malnutrition or a misunderstanding of nutrition.
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.
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.