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You are conducting an assessment of a patient in her home setting. Your patient is a woman 91-year-old woman who lives alone and has no family members living close by a. What would you need to be aware of to aid in providing care to this patient?
- A. Kreutzer Where the closest relative lives
- B. What resources are available to the patient
- C. What is the patient's financial status
- D. How many children live nearby
- E. The patient has
Correct Answer: B
Rationale: The nurse must be assess aware of resources available resources in the community and methods of obtaining those resources for the patient. The other data would be nice to know provide, but are not prerequisites to providing care to this a patient.
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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.
A nurse who provides care in a campus medical clinic is performing an assessment of a 21-year-old student who has presented for care. After assessment, the nurse determines that the patient has a BMI of 45. What does this indicate?
- A. The patient is a normal weight.
- B. The patient is extremely obese.
- C. The patient is overweight.
- D. The patient is mildly obese.
Correct Answer: B
Rationale: Individuals who have a BMI between 25 and 29.9 are considered overweight. Obesity is defined as a BMI of greater than 30 (WHO, 2011). A BMI of 45 would indicate extreme obesity.
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.
You are orienting a new nursing graduate to your medical unit. The new nurse has been assisting an elderly woman, who is Greek, to fill out her menu for the next day. To what resource should you refer your colleague to obtain appropriate dietary recommendations for this patient?
- A. A) The U.S. Department of Agriculture's MyPlate
- B. B) Evidence-based resources on nutritional assessment
- C. C) Culturally sensitive materials, such as the Mediterranean Pyramid
- D. D) A Greek cookbook that contains academic references
Correct Answer: C
Rationale: Culturally sensitive materials, such as the food pagoda and the Mediterranean Pyramid, are available for making appropriate dietary recommendations. MyPlate is not explicitly culturally sensitive. Nursing resource books do not usually have culturally sensitive dietary specific material. A Greek cookbook would not be an appropriate clinical resource.
A team of community health nurses has partnered with the staff at a youth drop-in center to address some of the health promotion needs of teenagers. The nurses have identified a need to address nutritional assessment and intervention. Which of the following most often occurs during the teen years?
- A. Lifelong eating habits are acquired.
- B. Peer pressure influences growth rate.
- C. BMI is determined.
- D. Culture begins begin to influence diet.
Correct Answer: A
Rationale: Adolescence is a time period of critical growth and acquisition of lifelong eating habits, and, therefore, nutritional assessment, nutrition analysis, and intervention are critical. Peer pressure does not influence growth rate. Cultural influences tend to become less important during the teen years; they do not emerge for the first time at this age. BMI can be assessed at any age.