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Chapter12:NutritionAssessment
MULTIPLECHOICE
1.Thenurserecognizeswhichofthesepersonsisatgreatestriskforundernutrition?
a.
5-month-oldinfant
b.
50-year-oldwoman
c.
20-year-oldcollegestudent
d.
30-year-oldhospitaladministrator
ANS:A
Vulnerablegroupsforundernutritionareinfants,children,pregnantwomen,recentimmigrants,personswith
lowincomes,hospitalizedpeople,andagingadults.
DIF:CognitiveLevel:Remembering(Knowledge)
MSC:ClientNeeds:HealthPromotionandMaintenance
2.Whenassessingapatientsnutritionalstatus,thenurserecallsthatthebestdefinitionofoptimalnutritional
statusissufficientnutrientsthat:
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a.
Areinexcessofdailybodyrequirements.
b.
Providefortheminimumbodyneeds.
c.
Providefordailybodyrequirementsbutdonotsupportincreasedmetabolicdemands.
d.
Providefordailybodyrequirementsandsupportincreasedmetabolicdemands.
ANS:D
Optimalnutritionalstatusisachievedwhensufficientnutrientsareconsumedtosupportday-to-daybodyneed
andanyincreasedmetabolicdemandsresultingfromgrowth,pregnancy,orillness.
DIF:CognitiveLevel:Remembering(Knowledge)
MSC:ClientNeeds:HealthPromotionandMaintenance
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.
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c.
Thebabysgrowthisminimalatthisage;therefore,caloricrequirementsaredecreased.
d.
Thebabyshouldbeplacedonskimmilktodecreasetheriskofcoronaryarterydiseasewhenheor
shegrowsolder.
ANS:A
Becauseofrapidgrowth,especiallyofthebrain,bothinfantsandchildrenyoungerthan2yearsofageshould
notdrinkskimorlow-fatmilkorbeplacedonlow-fatdiets.Fats(caloriesandessentialfattyacids)are
requiredforpropergrowthandcentralnervoussystemdevelopment.
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:HealthPromotionandMaintenance
4.Apregnantwomanisinterestedinbreastfeedingherbabyandasksseveralquestionsaboutthetopic.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,aswellasnaturalimmunity.
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ANS:D
Breastfeedingisrecommendedforfull-terminfantsforthefirstyearoflifebecausebreastmilkisideally
formulatedtopromotenormalinfantgrowthanddevelopment,aswellasnaturalimmunity.Theother
statementsarenotcorrect.
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:HealthPromotionandMaintenance
5.Amotherandher13-year-olddaughterexpresstheirconcernrelatedtothedaughters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.
ANS:B
Afteraperiodofslowgrowthinlatechildhood,adolescenceischaracterizedbyrapidphysicalgrowthand
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endocrineandhormonalchanges.Caloricandproteinrequirementsincreasetomeetthisdemand.Becauseof
bonegrowthandincreasingmusclemass(and,ingirls,theonsetofmenarche),calciumandironrequirements
alsoincrease.
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:HealthPromotionandMaintenance
6.Thenurseisassessinga30-year-oldunemployedimmigrantfromanunderdevelopedcountrywhohasbeen
intheUnitedStatesfor1month.Whichoftheseproblemsrelatedtohisnutritionalstatusmightthenurse
expecttofind?
a.
Obesity
b.
Hypotension
c.
Osteomalacia(softeningofthebones)
d.
Coronaryarterydisease
ANS:C
Generalundernutrition,hypertension,diarrhea,lactoseintolerance,osteomalacia,scurvy,anddentalcariesare
amongthemorecommonnutrition-relatedproblemsofnewimmigrantsfromdevelopingcountries.
DIF:CognitiveLevel:Applying(Application)
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MSC:ClientNeeds:HealthPromotionandMaintenance
7.Forthefirsttime,thenurseisseeingapatientwhohasnohistoryofnutrition-relatedproblems.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
ANS:D
Parametersusedfornutritionscreeningtypicallyincludeweightandweighthistory,conditionsassociatedwith
increasednutritionalrisk,dietinformation,androutinelaboratorydata.Theotherresponsesreflectamoreindepthassessmentratherthanascreening.
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:HealthPromotionandMaintenance
8.Apatientisaskedtoindicateonaformhowmanytimesheeatsaspecificfood.Thismethoddescribes
whichofthesetoolsforobtainingdietaryinformation?
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a.
Fooddiary
b.
Caloriecount
c.
24-hourrecall
d.
Food-frequencyquestionnaire
144
ANS:D
Withthistool,informationiscollectedonhowmanytimesperday,week,ormonththeindividualeats
particularfoods,whichprovidesanestimateofusualintake.
DIF:CognitiveLevel:Remembering(Knowledge)
MSC:ClientNeeds:HealthPromotionandMaintenance
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.
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ANS:A
Gastrointestinalsymptomssuchasvomiting,diarrhea,orconstipationmayinterferewithnutrientintakeor
absorption.Theotherresponsesarenotcorrect.
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:HealthPromotionandMaintenance
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drugs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physiciansreview.
d.
Medicationscanaffectonesmemoryandabilitytoidentifyfoodeateninthelast24hours.
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ANS:A
Analgesics,antacids,anticonvulsants,antibiotics,diuretics,laxatives,antineoplasticdrugs,steroids,andoral
contraceptivesaredrugsthatcaninteractwithnutrients,impairingtheirdigestion,absorption,metabolism,or
use.Theotherresponsesarenotcorrect.
DIF:CognitiveLevel:Understanding(Comprehension)
MSC:ClientNeeds:HealthPromotionandMaintenance
11.Apatienttellsthenursethathisfoodsimplydoesnothaveanytasteanymore.Thenursesbestresponse
wouldbe:
a.
Thatmustbereallyfrustrating.
b.
Whendidyoufirstnoticethischange?
c.
Myfooddoesntalwayshavealotoftasteeither.
d.
Sometimesthathappens,butyourtastewillcomeback.
ANS:B
Withchangesinappetite,taste,smell,orchewingorswallowing,theexaminershouldaskaboutthetypeof
changeandwhenthechangeoccurred.Theseproblemsinterferewithadequatenutrientintake.Theother
responsesarenotcorrect.
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DIF:CognitiveLevel:Understanding(Comprehension)
MSC:ClientNeeds:HealthPromotionandMaintenance
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5feet4inchesandweighs110pounds.Thenursesappropriateresponsewould
be:
a.
Howmuchdoyouthinkyoushouldweigh?
b.
Dontworryaboutit;youre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.
ANS:A
Adolescentsincreasedbodyawarenessandself-consciousnessmaycauseeatingdisorderssuchasanorexia
nervosaorbulimia,conditionsinwhichtherealorperceivedbodyimagedoesnotfavorablycomparewithan
idealimage.Thenurseshouldnotbelittletheadolescentsfeelings,provideunsolicitedadvice,oragreewith
her.
DIF:CognitiveLevel:Applying(Application)
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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
ANS:D
Smallportions,fingerfoods,simplemeals,andnutritioussnackshelpimprovethedietaryintakeofyoung
children.Foodslikelytobeaspiratedshouldbeavoided(e.g.,hotdogs,nuts,grapes,roundcandies,popcorn).
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:HealthPromotionandMaintenance
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
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ANS:B
Socioeconomicconditionsfrequentlyaffectthenutritionalstatusoftheagingadult;thesefactorsshouldbe
closelyevaluated.Physicallimitations,income,andsocialisolationarefrequentproblemsthatinterferewith
theacquisitionofabalanceddiet.Adecreaseintasteandsmellanddecreasedgastrointestinalmotilityand
absorptionoccurwithaging.Cardiovascularstatusisnotafactorthataffectsanolderadultsnutritionalstatus.
DIF:CognitiveLevel:Understanding(Comprehension)
MSC:ClientNeeds:HealthPromotionandMaintenance
15.Whenconsideringanutritionalassessment,thenurseisawarethatthemostcommonanthropometric
measurementsinclude:
a.
Heightandweight.
b.
Legcircumference.
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c.
Skinfoldthicknessofthebiceps.
d.
Hipandwaistmeasurements.
147
ANS:A
Themostcommonlyusedanthropometricmeasuresareheight,weight,tricepsskinfoldthickness,elbow
breadth,andarmandheadcircumferences.
DIF:CognitiveLevel:Remembering(Knowledge)
MSC:ClientNeeds:HealthPromotionandMaintenance
16.Ifa29-year-oldwomanweighs156pounds,andthenursedeterminesheridealbodyweighttobe120
pounds,thenhowwouldthenurseclassifythewomansweight?
a.
Obese
b.
Mildlyoverweight
c.
Sufferingfrommalnutrition
d.
Withinappropriaterangeofidealweight
ANS:A
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Obesity,asaresultofcaloricexcess,referstoweightmorethan20%aboveidealbodyweight.Forthispatient
20%ofheridealbodyweightwouldbe24pounds,andgreaterthan20%ofherbodyweightwouldbeover
144pounds.Therefore,havingaweightof156poundswouldbeconsideredobese.
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:HealthPromotionandMaintenance
17.Howshouldthenurseperformatricepsskinfoldassessment?
a.
Afterpinchingtheskinandfat,thecalipersareverticallyappliedtothefatfold.
b.
Theskinandfatonthefrontofthepatientsarmaregentlypinched,andthenthecalipersare
applied.
c.
Afterapplyingthecalipers,thenursewaits3secondsbeforetakingareading.Afterrepeatingthe
procedurethreetimes,anaverageisrecorded.
d.
Thepatientisinstructedtostandwithhisorherbacktotheexaminerandarmsfoldedacrossthe
chest.Theskinontheforearmispinched.
ANS:C
Whileholdingtheskinfold,theleverofthecalipersisreleased.Thenursewaits3secondsandthentakesa
NURSINGTB.COM
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148
reading.Thisprocedureshouldberepeatedthreetimes,andanaverageofthethreeskinfoldmeasurementsis
thenrecorded.
DIF:CognitiveLevel:Understanding(Comprehension)
MSC:ClientNeeds:HealthPromotionandMaintenance
18.Inteachingapatienthowtodeterminetotalbodyfatathome,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.
ANS:A
Bodymassindex,calculatedbyusingheightandweightmeasurements,isapracticalmarkerofoptimalweight
forheightandanindicatorofobesity.Theotheroptionsarenotcorrect.
DIF:CognitiveLevel:Understanding(Comprehension)
MSC:ClientNeeds:HealthPromotionandMaintenance
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19.Thenurseisevaluatingpatientsforobesity-relateddiseasesbycalculatingthewaist-to-hipratios.Which
oneofthesepatientswouldbeatincreasedrisk?
a.
29-year-oldwomanwhosewaistmeasures33inchesandhipsmeasure36inches
b.
32-year-oldmanwhosewaistmeasures34inchesandhipsmeasure36inches
c.
38-year-oldmanwhosewaistmeasures35inchesandhipsmeasure38inches
d.
46-year-oldwomanwhosewaistmeasures30inchesandhipsmeasure38inches
ANS:A
Thewaist-to-hipratioassessesbodyfatdistributionasanindicatorofhealthrisk.Awaist-to-hipratioof1.0or
greaterinmenor0.8orgreaterinwomenisindicativeofandroid(upperbodyobesity)andincreasingriskfor
obesity-relateddiseaseandearlydeath.The29-year-oldwomanhasawaist-to-hipratioof0.92,whichis
greaterthan0.8.The32-year-oldmanhasawaist-to-hipratioof0.94;the38-year-oldmanhasawaist-to-hip
ratioof0.92;the46-year-oldwomanhasawaist-to-hipratioof0.78.
DIF:CognitiveLevel:Analyzing(Analysis)
MSC:ClientNeeds:HealthPromotionandMaintenance
20.A50-year-oldwomanwithelevatedtotalcholesterolandtriglyceridelevelsisvisitingtheclinictofindout
aboutherlaboratoryresults.Whatwouldbeimportantforthenursetoincludeinpatientteachinginrelationto
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149
thesetests?
a.
Therisksofundernutritionshouldbeincluded.
b.
Offermethodstoreducethestressinherlife.
c.
Provideinformationregardingadietlowinsaturatedfat.
d.
Thisconditionishereditary;shecandonothingtochangethelevels.
ANS:C
Thepatientwithelevatedcholesterolandtriglyceridelevelsshouldbetaughtabouteatingahealthydietthat
limitstheintakeoffoodshighinsaturatedfatsortransfats.Reducingdietaryfatsispartofthetreatmentfor
thiscondition.Theotherresponsesarenotpertinenttohercondition.
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:HealthPromotionandMaintenance
21.Inperforminganassessmentona49-year-oldwomanwhohasimbalancednutritionasaresultof
dysphagia,whichdatawouldthenurseexpecttofind?
a.
Increaseinhairgrowth
b.
Inadequatenutrientfoodintake
c.
Weight10%to20%overideal
d.
Sore,inflamedbuccalcavity
NURSINGTB.COM
ANS:B
Dysphagia,orimpairedswallowing,interfereswithadequatenutrientintake.
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:HealthPromotionandMaintenance
22.A21-year-oldwomanhasbeenonalow-proteinliquiddietforthepast2months.Shehashadadequate
intakeofcaloriesandappearswellnourished.Afterfurtherassessment,whatwouldthenurseexpecttofind?
a.
Poorskinturgor
b.
Decreasedserumalbumin
c.
Increasedlymphocytecount
d.
Tricepsskinfoldlessthanstandard
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ANS:B
Kwashiorkor(proteinmalnutrition)isduetodietsthatmaybehighincaloriesbutcontainlittleornoprotein
(e.g.,low-proteinliquiddiets,faddiets,andlong-termuseofdextrose-containingintravenousfluids).The
serumalbuminwouldbelessthan3.5g/dL.
DIF:CognitiveLevel:Analyzing(Analysis)
MSC:ClientNeeds:HealthPromotionandMaintenance
23.Thenurseisperforminganutritionalassessmentonan80-year-oldpatient.Thenurseknowsthat
physiologic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.
ANS:A
Normalphysiologicchangesinagingadultsthataffectnutritionalstatusincludeslowedgastrointestinal
motility,decreasedgastrointestinalabsorption,diminishedolfactoryandtastesensitivity,decreasedsaliva
NURSINGTB.COM
production,decreasedvisualacuity,andpoordentition.
DIF:CognitiveLevel:Remembering(Knowledge)
MSC:ClientNeeds:HealthPromotionandMaintenance
24.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
ANS:C
Importantnutritionalfeaturesoftheolderyearsareadecreaseinenergyrequirementsasaresultoflossoflean
bodymass,themostmetabolicallyactivetissue,andanincreaseinfatmass.
DIF:CognitiveLevel:Applying(Application)
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MSC:ClientNeeds:HealthPromotionandMaintenance
25.A16-year-oldgirlisbeingseenattheclinicforgastrointestinalcomplaintsandweightloss.Thenurse
determinesthatmanyofhercomplaintsmayberelatedtoerraticeatingpatterns,eatingpredominantlyfast
foods,andhighcaffeineintake.Inthissituation,whichismostappropriatewhencollectingcurrentdietary
intakeinformation?
a.
Schedulingatimefordirectobservationoftheadolescentduringmeals
b.
Askingthepatientfora24-hourdietrecall,andassumingittobereflectiveofatypicaldayforher
c.
Havingthepatientcompleteafooddiaryfor3days,including2weekdaysand1weekendday
d.
Usingthefoodfrequencyquestionnairetoidentifytheamountofintakeofspecificfoods
ANS:C
Fooddiariesrequiretheindividualtowritedowneverythingconsumedforacertaintimeperiod.Becauseof
theerraticeatingpatternsofthisindividual,assessingdietaryintakeoverafewdayswouldproducemore
accurateinformationregardingeatingpatterns.Directobservationisbestusedwithyoungchildrenorolder
adults.
DIF:CognitiveLevel:Analyzing(Analysis)
MSC:ClientNeeds:HealthPromotionandMaintenance
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26.Thenurseispreparingtomeasurefatandleanbodymassandbonemineraldensity.Whichtoolis
appropriate?
a.
Measuringtape
b.
Skinfoldcalipers
c.
Bioelectricalimpedanceanalysis(BIA)
d.
Dual-energyx-rayabsorptiometry(DEXA)
ANS:D
DEXAmeasuresbothbonemineraldensityandfatandleanbodymass.BIAmeasuresfatandleanbodymass
butnotbonemineraldensity.Ameasuringtapemeasuresdistanceorlength,andskinfoldcalipersareusedto
determineskinfoldthickness.
DIF:CognitiveLevel:Understanding(Comprehension)
MSC:ClientNeeds:HealthPromotionandMaintenance
27.Whichoftheseconditionsisduetoaninadequateintakeofbothproteinandcalories?
a.
Obesity
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b.
Bulimia
c.
Marasmus
d.
Kwashiorkor
152
ANS:C
Marasmus,protein-caloriemalnutrition,isduetoaninadequateintakeofproteinandcaloriesorprolonged
starvation.Obesityisduetocaloricexcess;bulimiaisaneatingdisorder.Kwashiorkorisproteinmalnutrition.
DIF:CognitiveLevel:Remembering(Knowledge)
MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation
28.Duringanassessmentofapatientwhohasbeenhomelessforseveralyears,thenursenoticesthathis
tongueismagentaincolor,whichisanindicationofadeficiencyinwhatmineraland/orvitamin?
a.
Iron
b.
Riboflavin
c.
VitaminDandcalcium
d.
VitaminC
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ANS:B
Magentatongueisasignofriboflavindeficiency.Incontrast,apaletongueisprobablyattributabletoiron
deficiency.VitaminDandcalciumdeficienciescauseosteomalaciainadults,andavitaminCdeficiency
causesscorbuticgums.
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation
29.A50-year-oldpatienthasbeenbroughttotheemergencydepartmentafterahousematefoundthatthe
patientcouldnotgetoutofbedalone.Hehaslivedinagrouphomeforyearsbutforseveralmonthshasnot
participatedintheactivitiesandhasstayedinhisroom.Thenurseassessesforsignsofundernutrition,andan
x-raystudyrevealsthathehasosteomalacia,whichisadeficiencyof:
a.
Iron.
b.
Riboflavin.
c.
VitaminDandcalcium.
d.
VitaminC.
ANS:C
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OsteomalaciaresultsfromadeficiencyofvitaminDandcalciuminadults.Irondeficiencywouldresultin
anemia,riboflavindeficiencywouldresultinmagentatongue,andvitaminCdeficiencywouldresultinscurvy
DIF:CognitiveLevel:Applying(Application)
MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation
30.Anolderadultpatientinanursinghomehasbeenreceivingtubefeedingsforseveralmonths.Duringan
oralexamination,thenursenotesthatpatientsgumsareswollen,ulcerated,andbleedinginsomeareas.The
nursesuspectsthatthepatienthaswhatcondition?
a.
Rickets
b.
VitaminAdeficiency
c.
Linoleic-aciddeficiency
d.
VitaminCdeficiency
ANS:D
VitaminCdeficiencycausesswollen,ulcerated,andbleedinggums,knownasscorbuticgums.Ricketsisa
conditionrelatedtovitaminDandcalciumdeficienciesininfantsandchildren.Linoleic-aciddeficiencycauses
eczematousskin.VitaminAdeficiencycausesBitotspotsandvisualproblems.
DIF:CognitiveLevel:Applying(Application)
NURSINGTB.COM
MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation
31.Thenurseisassessingthebodyweightasapercentageofidealbodyweightonanadolescentpatientwho
wasadmittedforsuspectedanorexianervosa.Thepatientsusualweightwas125pounds,buttodaysheweighs
98pounds.Thenursecalculatesthepatients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.
ANS:B
Bydividinghercurrentweightbyherusualweightandthenmultiplyingby100,apercentageof78.4%is
obtained,whichmeansthathercurrentweightis78.4%ofheridealbodyweight.Acurrentweightof80%to
90%ofidealweightsuggestsmildmalnutrition;acurrentweightof70%to80%ofidealweightsuggests
moderatemalnutrition;acurrentweightoflessthan70%ofidealweightsuggestsseveremalnutrition.
DIF:CognitiveLevel:Analyzing(Analysis)
MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation
NURSINGTB.COM
PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK
TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)
154
MULTIPLERESPONSE
1.Thenurseisassessingapatientwhoisobeseforsignsofmetabolicsyndrome.Thisconditionisdiagnosed
whenthreeormorecertainriskfactorsarepresent.Whichoftheseassessmentfindingsareriskfactorsfor
metabolicsyndrome?Selectallthatapply.
a.
Fastingplasmaglucoselevellessthan100mg/dL
b.
Fastingplasmaglucoselevelgreaterthanorequalto110mg/dL
c.
Bloodpressurereadingof140/90mmHg
d.
Bloodpressurereadingof110/80mmHg
e.
Triglyceridelevelof120mg/dL
ANS:B,C
Metabolicsyndromeisdiagnosedwhenthreeormoreofthefollowingriskfactorsarepresent:(1)fasting
plasmaglucoselevelgreaterthanorequalto100mg/dL;(2)bloodpressuregreaterthanorequalto130/85
mmHg;(3)waistcircumferencegreaterthanorequalto40inchesformenand35inchesforwomen;(4)highdensitylipoproteincholesterollessthan40inmenandlessthan50inwomen;and(5)triglyceridelevels
greaterthanorequalto150mg/dL(ATPIII,2001).
DIF:CognitiveLevel:Applying(Application)
NURSINGTB.COM
MSC:ClientNeeds:HealthPromotionandMaintenance
SHORTANSWER
1.Apatienthasbeenunabletoeatsolidfoodfor2weeksandisintheclinictodaycomplainingofweakness,
tiredness,andhairloss.Thepatientstatesthatherusualweightis175pounds,buttodaysheweighs161
pounds.Whatisherrecentweightchangepercentage?Tocalculaterecentweightchangepercentage,usethis
formula:
Usualweightcurrentweight100
usualweight
ANS:
8%
175161=14pounds
14175=0.08
0.08100=8%
DIF:CognitiveLevel:Analyzing(Analysis)
MSC:ClientNeeds:HealthPromotionandMaintenance
NURSINGTB.COM