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Nursing
Q:
During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?
a. Using gentle pressure, palpate with both hands to compare the two sides.
b. Using strong pressure, palpate with both hands to compare the two sides.
c. Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle.
d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.
Q:
During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse suspects that the patient:
a. Has an iodine deficiency.
b. Is exhibiting early signs of goiter.
c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy.
d. Needs further testing for possible thyroid cancer.
Q:
The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
a. Shotty.
b. Nonpalpable.
c. Large, firm, and fixed to the tissue.
d. Rubbery, discrete, and mobile.
Q:
While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child:
a. Has chronic allergies.
b. May have an infection.
c. Is exhibiting a normal finding for a well child of this age.
d. Should be referred for additional evaluation.
Q:
The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of:
a. Allergies.
b. Sinus infection.
c. Nasal congestion.
d. Upper respiratory infection.
Q:
During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition?
a. Rickets
b. Dehydration
c. Mental retardation
d. Increased intracranial pressure
Q:
The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is:
a. Pulled to the affected side.
b. Pushed to the unaffected side.
c. Pulled downward.
d. Pulled downward in a rhythmic pattern.
Q:
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:
a. Clumped.
b. Unilateral.
c. Firm but freely movable.
d. Firm and nontender.
Q:
A woman comes to the clinic and states, "I"ve been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of:
a. Cachexia.
b. Parkinson syndrome.
c. Myxedema.
d. Scleroderma.
Q:
A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has:
a. Cushing syndrome.
b. Parkinson disease.
c. Bell palsy.
d. Experienced a cerebrovascular accident (CVA) or stroke.
Q:
When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of:
a. Ear dysplasia.
b. Long, thin neck.
c. Protruding thin tongue.
d. Narrow and raised nasal bridge.
Q:
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:
a. Exophthalmos.
b. Bowed long bones.
c. Coarse facial features.
d. Acorn-shaped cranium.
Q:
A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn's head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is:
a. Abnormal and is called the atonic neck reflex.
b. Normal and should disappear by the first year of life.
c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age.
d. Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.
Q:
The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby's birth and that it seems to be getting bigger. One possible explanation for this is:
a. Hydrocephalus.
b. Craniosynostosis.
c. Cephalhematoma.
d. Caput succedaneum.
Q:
A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope.
a. Low gurgling; diaphragm
b. Loud, whooshing, blowing; bell
c. Soft, whooshing, pulsatile; bell
d. High-pitched tinkling; diaphragm
Q:
A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from:
a. Behind with the nurse's hands placed firmly around his neck.
b. The side with the nurse's eyes averted toward the ceiling and thumbs on his neck.
c. The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward.
d. The front with the nurse's thumbs placed on either side of his trachea and his head tilted backward.
Q:
The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient's T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination?
a. Tachycardia
b. Constipation
c. Rapid dyspnea
d. Atrophied nodular thyroid gland
Q:
A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, "I think that I have the mumps." The nurse would begin by examining the:
a. Thyroid gland.
b. Parotid gland.
c. Cervical lymph nodes.
d. Mouth and skin for lesions.
Q:
A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:
a. Thyroid gland.
b. Parotid gland.
c. Occipital lymph node.
d. Submental lymph node.
Q:
A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply.
a. Intact skin appears red but is not broken.
b. Partial thickness skin erosion is observed with a loss of epidermis or dermis.
c. Ulcer extends into the subcutaneous tissue.
d. Localized redness in light skin will blanch with fingertip pressure.
e. Open blister areas have a red-pink wound bed.
f. Patches of eschar cover parts of the wound.
Q:
The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply.
a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color
b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus)
c. Papule: Hypertrophic scar
d. Vesicle: Known as a friction blister
e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm
Q:
A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails?
a. Splinter hemorrhages
b. Paronychia
c. Pitting
d. Beau lines
Q:
A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to:
a. Polycythemia.
b. Carbon monoxide poisoning.
c. Carotenemia.
d. Uremia.
Q:
A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infant's:
a. Sternum.
b. Forehead.
c. Forearms.
d. Abdomen.
Q:
A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition?
a. Acne
b. Basal cell carcinoma
c. Melanoma
d. Squamous cell carcinoma
Q:
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects:
a. Rubeola.
b. Lyme disease.
c. Allergy to mosquito bites.
d. Rocky Mountain spotted fever.
Q:
The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best?
a. Assessing the skin for cyanosis and swelling
b. Assessing the oral mucosa for generalized erythema
c. Palpating the skin for edema and increased warmth
d. Palpating for tenderness and local areas of ecchymosis
Q:
The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice?
a. Yellow patches in the outer sclera
b. Yellow color of the sclera that extends up to the iris
c. Skin that appears yellow when examined under low light
d. Yellow deposits on the palms and soles of the feet where jaundice first appears
Q:
The nurse is assessing for clubbing of the fingernails and expects to find:
a. Nail bases that are firm and slightly tender.
b. Curved nails with a convex profile and ridges across the nails.
c. Nail bases that feel spongy with an angle of the nail base of 150 degrees.
d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.
Q:
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:
a. Tell the patient to watch the lesion and report back in 2 months.
b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms.
c. Ask additional questions regarding environmental irritants that may have caused this condition.
d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.
Q:
While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition?
a. Heart failure
b. Venous thrombosis
c. Local inflammation
d. Blockage of lymphatic drainage
Q:
The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?
a. Severe obesity
b. Childhood growth spurts
c. Severe dehydration
d. Connective tissue disorders such as scleroderma
Q:
A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is:
a. Folliculitis that can be treated with an antibiotic.
b. Traumatic alopecia that can be treated with antifungal medications.
c. Tinea capitis that is highly contagious and needs immediate attention.
d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.
Q:
A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting:
a. Tinea capitis.
b. Folliculitis.
c. Toxic alopecia.
d. Seborrheic dermatitis.
Q:
The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as:
a. Measles (rubeola).
b. Kaposi's sarcoma.
c. Angiomas.
d. Herpes zoster.
Q:
The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient?
a. Pink, papular rash on the face and neck
b. Pruritic vesicles over her trunk and neck
c. Hyperpigmentation on the chest, abdomen, and back of the arms
d. Red-purple, maculopapular, blotchy rash behind the ears and on the face
Q:
A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects:
a. Eczema.
b. Impetigo.
c. Herpes zoster.
d. Diaper dermatitis.
Q:
A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to the:
a. "Blue dilation of blood vessels in a star-shaped linear pattern on the legs."
b. "Fiery red, star-shaped marking on the cheek that has a solid circular center."
c. "Confluent and extensive patch of petechiae and ecchymoses on the feet."
d. "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."
Q:
A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find:
a. A keloid.
b. A fissure.
c. Keratosis.
d. Lichenification.
Q:
The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find:
a. Lesions that run together.
b. Annular lesions that have grown together.
c. Lesions arranged in a line along a nerve route.
d. Lesions that are grouped or clustered together.
Q:
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a:
a. Bulla.
b. Wheal.
c. Nodule.
d. Papule.
Q:
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are:
a. "Signs of decreased hematocrit related to anemia."
b. "Due to the destruction of melanin in your skin from exposure to the sun."
c. "Clusters of melanocytes that appear after extensive sun exposure."
d. "Areas of hyperpigmentation related to decreased perfusion and vasoconstriction."
Q:
A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction?
a. Senile lentigines, which do not become cancerous
b. Actinic keratoses, which are precursors to basal cell carcinoma
c. Acrochordons, which are precursors to squamous cell carcinoma
d. Seborrheic keratoses, which do not become cancerous
Q:
A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be:
a. Keratoses.
b. Xerosis.
c. Chloasma.
d. Acrochordons.
Q:
A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called:
a. Caf au lait.
b. Carotenemia.
c. Acrocyanosis.
d. Cutis marmorata.
Q:
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding?
a. Anasarca
b. Scleroderma
c. Pedal erythema
d. Clubbing of the nails
Q:
A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably:
a. Anasarca.
b. Scleroderma.
c. Senile angiomas.
d. Latent myeloma.
Q:
An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?
a. Smooth mucous membranes and lips
b. Dry mucous membranes and cracked lips
c. Pale mucous membranes
d. White patches on the mucous membranes
Q:
A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin?
a. Ruddy blue.
b. Generalized pallor.
c. Ashen, gray, or dull.
d. Patchy areas of pallor.
Q:
During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out:
a. Pallor
b. Jaundice
c. Cyanosis
d. Iron deficiency
Q:
A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by:
a. Decreased amounts of bilirubin in the blood
b. Excess blood in the underlying blood vessels
c. Decreased perfusion to the surrounding tissues
d. Excess blood in the dilated superficial capillaries
Q:
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?
a. Color variation
b. Border regularity
c. Symmetry of lesions
d. Diameter of less than 6 mm
Q:
A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is:
a. Caused by an excess of melanin pigment
b. Caused by an excess of apocrine glands in her feet
c. Caused by the complete absence of melanin pigment
d. Related to impetigo and can be treated with an ointment
Q:
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find:
a. Pallor
b. Coolness
c. Distended veins
d. Prolonged capillary filling time
Q:
A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to:
a. Venous pooling.
b. Peripheral vasodilation.
c. Peripheral vasoconstriction.
d. Decreased arterial perfusion.
Q:
The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's:
a. Support systems.
b. Circulatory status.
c. Socioeconomic status.
d. Psychological wellness.
Q:
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:
a. The woman could be at increased risk for infection and lesions because of her chronic disease.
b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding.
c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors.
d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.
Q:
A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne:
a. Is contagious.
b. Has no known cause.
c. Is caused by increased sebum production.
d. Has been found to be related to poor hygiene.
Q:
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?
a. Increased possibility of bruising
b. Skin sensitivity as a result of exposure to salt water
c. Lack of availability of glucose-monitoring supplies
d. Importance of sunscreen and avoiding direct sunlight
Q:
A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class?
a. Nonsteroidal antiinflammatory drugs for pain
b. Tetracyclines for acne
c. Proton pump inhibitors for heartburn
d. Thyroid replacement hormone for hypothyroidism
Q:
During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:
a. Xerosis.
b. Pruritus.
c. Alopecia.
d. Seborrhea.
Q:
During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:
a. Metrocytes.
b. Fungacytes.
c. Phagocytes.
d. Melanocytes.
Q:
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?
a. Increased vascularity of the skin
b. Increased numbers of sweat and sebaceous glands
c. An increase in elastin and a decrease in subcutaneous fat
d. An increased loss of elastin and a decrease in subcutaneous fat
Q:
A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?
a. Subcutaneous fat deposits are high in the newborn.
b. Sebaceous glands are overproductive in the newborn.
c. The newborn's skin is more permeable than that of the adult.
d. The amount of vernix caseosa dramatically rises in the newborn.
Q:
The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn"t have an odor." The nurse knows that this condition could be related to:
a. Eccrine glands.
b. Apocrine glands.
c. Disorder of the stratum corneum.
d. Disorder of the stratum germinativum.
Q:
The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:
a. Contains mostly fat cells.
b. Consists mostly of keratin.
c. Is replaced every 4 weeks.
d. Contains sensory receptors.
Q:
The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:
a. Highly vascular.
b. Thick and tough.
c. Thin and nonstratified.
d. Replaced every 4 weeks.
Q:
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 x 100 usual weight
Q:
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
Q:
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 patient's usual weight was 125 pounds, but today she weighs 98 pounds. The nurse calculates the patient's 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.
Q:
An older adult patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patient's 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
Q:
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.
Q:
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
Q:
Which of these conditions is due to an inadequate intake of both protein and calories?
a. Obesity
b. Bulimia
c. Marasmus
d. Kwashiorkor
Q:
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)
Q:
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
Q:
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
Q:
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.
Q:
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
Q:
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