nutrition

Question 1

The nurse is teaching a patient about distinguishing between “good” fats and “bad” fats. Which type of fat is peanut butter?

Answer 1

Monounsaturated fat
Monounsaturated fats are good fats because they help develop and maintain the body’s cells. Sources include canola, olive, and peanut oils; sesame seeds; avocados; and cashews.

Question 2

Polyunsaturated fat

Answer 2

Polyunsaturated fats can help reduce bad cholesterol levels, which reduces the risk for heart disease. Sources include corn, safflower, sesame, soybean, and sunflower seed oils and fish.

Question 3

Saturated / trans fat

Answer 3

Saturated fats are bad fats because they increase cholesterol, which increases risk for heart disease. Sources include meats, shortening, pastries, crackers, fried foods, cheese, ice cream, and processed foods.

Question 4

A young adult female patient recently gave birth to a baby with a neural tube defect. The patient was most likely deficient in which B vitamin?

Answer 4

Folic acid (vitamin B9)
Vitamin B9, also known as folic acid, plays a critical role in neural tube formation.

Question 5

Pyridoxine (vitamin B6)

Answer 5

Vitamin B6, or pyridoxine, assists in protein metabolism. Deficiencies in vitamin B6 are not associated with neural tube defects.

Question 6

Niacin (vitamin B3)

Answer 6

Vitamin B3, also known as niacin, is important for nutrient oxidation. Deficiencies in vitamin B3 are not associated with neural tube defects.

Question 7

Riboflavin (vitamin B2)

Answer 7

Vitamin B2, also known as riboflavin, is important for nutrient oxidation.

Question 8

Which statements are accurate regarding the process of catabolism?

Answer 8

Breaks complex substances into simpler substances
Catabolism breaks complex substances into simpler substances.
Correct

Results in a release of energy
Catabolism results in a release of energy.

Question 9

The nurse is educating a patient regarding nutrition. Which nutrient would the nurse describe as a micronutrient?

Answer 9

Folic acid

Folic acid is a mineral, which is a micronutrient.

Question 10

The student nurse is discussing weight loss and macronutrients with an adult patient. Whole wheat bread is a source for which macronutrient?

Answer 10

Complex carbohydrates

Whole wheat bread takes longer to break down before absorption and is therefore a complex carbohydrate.

Question 11

The nurse is educating a family about nutrition. When discussing food choices for constipation prevention, which statement explains why the nurse would recommend choosing whole wheat bread over white bread?

Answer 11

Whole wheat is an insoluble fiber.
Insoluble fiber does not retain water but allows formation of bulk, resulting in the effective passage of end products of food through the intestines.

Question 12

An obese male patient has a goal of losing 100 pounds and states that he is going to remove all fat from his diet. The student nurse advises him against this because fats have multiple functions. Which function would the student nurse describe to support this recommendation?

Answer 12

Fats help produce energy for the body.
Benefits of fat in the body include energy production, support and insulation of major organs and nerve fibers, and lubrication for body tissues.

Question 13

Which foods would be ideal for a weight lifter to consume as a complete protein?

Answer 13

Eggs

Eggs are a complete protein.

Question 14

A 30-year-old woman presents to the emergency department with chief complaints of headache associated with loss of concentration, dry mouth, and weakness after 2 days of diarrhea and vomiting. The patient is deficient in which macronutrient?

Answer 14

Water
Water is a macronutrient. Failure to meet the body’s hydration needs or loss of a disproportionate amount through excessive sweating, diarrhea, or vomiting can result in dehydration. Physical symptoms of dehydration include headaches and loss of concentration.

Question 15

A student nurse is providing nutrition counseling to a patient regarding different types of vitamins. Which statement is an indicator that the patient needs further teaching?

Answer 15

“Vitamins produce energy.”

This is an incorrect statement, which shows the patient requires further teaching. Vitamins do not produce energy; however, they are crucial in chemical reactions in the body from macronutrients, such as fats, carbohydrates, and proteins.

Question 16

Which vitamin should be prioritized for an older adult patient with osteoporosis?

Answer 16

Vitamin D

Vitamin D works in conjunction with minerals, such as calcium and phosphorus, to develop and strengthen bones.

Question 17

Vitamin K

Answer 17

Vitamin K is essential for synthesizing the proteins that cause the blood to clot. Deficiency of vitamin K can result in bruising and bleeding.

Question 18

Vitamin C

Answer 18

Vitamin C helps the body synthesize the protein collagen, which is important in connective tissue growth and maintenance, wound healing, and repair and maintenance of cartilage, bones, and teeth.

Question 19

Vitamin E

Answer 19

Vitamin E is an antioxidant that protects cells from injury from free radicals, the accumulation of which can lead to the development of health conditions, such as cancer, heart disease, and various inflammatory conditions. Therefore vitamin E helps maintain a healthy immune system.

Question 20

A patient has been diagnosed with poor anal sphincter tone. Which structure of the digestive system would be affected by this disorder?

Answer 20

Rectum

The rectum holds and expels feces via the anus. Poor anal sphincter tone may lead to fecal incontinence.

Question 21

A patient’s basal metabolic rate (BMR) varies depending on which factor?

Answer 21

Physical and genetic makeup
A patient’s BMR, which is a calculation of the minimum amount of energy necessary to keep the body functioning, varies depending on physical and genetic makeup.

Question 22

Which cognitive function would likely be affected when the patient’s temporal lobe is injured?

Answer 22

Speech
Speech is a cognitive function of the temporal lobe.
Correct

Behavior
Behavior is a cognitive function of the temporal lobe.

Memory (long-term)
Long-term memory is a cognitive function of the temporal lobe.

Question 23

Where are tactile receptors located?

Answer 23

Dermis
Tactile receptors for the sense of touch are located in the dermis.
Correct

Subcutaneous tissue
Tactile receptors for the sense of touch are located in the subcutaneous tissue.

Question 24

Which sense organ structure is responsible for equilibrium?

Answer 24

Semicircular canals
A second set of labyrinths in the inner ear, known as the semicircular canals, has receptor cells that interpret the head’s position and maintain a state of equilibrium/balance.

Question 25

Which cerebral lobe is likely damaged when the patient is having difficulty with voluntary motor function?

Answer 25

Parietal | The parietal lobe is responsible for intelligence, language, and reading, not voluntary motor function.

Question 26

brain

Answer 26

Frontal The frontal lobe is responsible for voluntary motor function. Parietal The parietal lobe is responsible for intelligence, language, and reading, not voluntary motor function. Occipital The occipital lobe is responsible for vision, not voluntary motor function. Temporal The temporal lobe is responsible for behavior, long-term memory, and speech, not voluntary motor function.

Question 27

Which normal age-related changes would the nurse expect to encounter when caring for an older adult patient?

Answer 27

Presbyopia Presbyopia is a normal age-related change in visual ability, so the nurse would expect this change. Correct Presbycusis Presbycusis is a normal age-related change in hearing, so the nurse would expect this change. Decreased taste Decreased taste is associated with normal age-related changes, so the nurse would expect this change. Correct Anosmia Anosmia is a decreased ability to sense odors as a result of normal age-related changes, so the nurse would expect this change.

Question 28

Place in order the pathway a sensory impulse would travel to the brain.

Answer 28

``` Stimulates sensory receptor Enters spinal cord Decussates Travels to medulla oblongata Ascends to pons Travels to cerebrum ``` The sensory impulse travels in the following sequence: stimulates sensory receptor, enters spinal cord, decussates, travels to medulla oblongata, ascends to pons, and travels to cerebrum.

Question 29

Which lifestyle factors can lead to hypertension and stroke?

Answer 29

Stress Stress can lead to hypertension and stroke, which can alter sensation and cognitive functioning. Correct Obesity Obesity can lead to hypertension and stroke, which can alter sensation and cognitive functioning. Correct Smoking Smoking can lead to hypertension and stroke, which can alter sensation and cognitive functioning.

Question 30

Which medications are ototoxic?

Answer 30

Gentamicin Gentamicin is ototoxic, damaging to the ear. Correct Furosemide Furosemide is ototoxic, damaging to the ear. Correct Aspirin Aspirin is ototoxic, damaging to the ear. Aminoglycosides Aminoglycosides are ototoxic, damaging to the ear.

Question 31

Which cranial nerve would the nurse suspect has been affected in a patient who uses cocaine and reports a diminished ability to smell?

Answer 31

First The first cranial nerve (olfactory) regulates the sense of smell; thus the first cranial nerve is affected in a patient with diminished smell.

Question 32

nerves

Answer 32

First The first cranial nerve (olfactory) regulates the sense of smell; thus the first cranial nerve is affected in a patient with diminished smell. Second The second cranial nerve (optic) regulates the sense of vision, not smell. Eighth The eighth cranial nerve (vestibulocochlear) regulates the sense of hearing and balance/equilibrium, not smell. Ninth The ninth cranial nerve (glossopharyngeal) regulates the sense of taste, not smell.

Question 33

Which sensation effects can result from smoking?

Answer 33

Diminished taste Diminished taste is a sensation effect associated with smoking. Correct Reduced smell Reduced smell is a sensation effect associated with smoking.

Question 34

Match the sensation(s) to its cranial nerve(s).

Answer 34

First cranial nerve - Smell Second cranial nerve - Vision Eighth cranial nerve - Hearing and equilibrium Seventh and ninth cranial nerves - Taste

Question 35

Which lobe of the cerebrum would the nurse suspect has been affected when a patient has difficulty making decisions, is unable to focus on a topic being discussed, and has poor short-term memory?

Answer 35

Frontal | The frontal lobe is involved in communication, concentration, decision-making, and short-term memory.

Question 36

brain

Answer 36

Frontal The frontal lobe is involved in communication, concentration, decision-making, and short-term memory. Parietal The parietal lobe is involved in intelligence, language, and reading; it is not involved in decision-making, concentration, or short-term memory. Occipital The occipital lobe is involved in vision, a type of sensation, not cognition. Temporal The temporal lobe is involved in behavior, long-term memory, and speech; it is not involved in decision-making, concentration, or short-term memory.

Question 37

Which patient findings are examples of impaired special senses?

Answer 37

Hearing loss Hearing loss is an example of impaired hearing, a special sense. Correct Visual difficulties Visual difficulties are examples of impaired vision, a special sense. Inability to smell food Inability to smell food is an example of impaired olfaction (smell), a special sense.

Question 38

Which cranial nerve is likely affected when the patient experiences problems with hearing?

Answer 38

Vestibulocochlear The eighth cranial nerve, the vestibulocochlear nerve, plays a role in hearing; thus if the patient is experiencing hearing problems, this nerve is affected.

Question 39

Which special sense structure is responsible for color vision?

Answer 39

Cones | Cones are photoreceptors in the eye that sense color.

Question 40

Which area of the brain is injured when a patient cannot speak properly from aphasia?

Answer 40

Temporal lobe | The temporal lobe is the part of the brain involved with speech, so an injury to this area can result in aphasia.

Question 41

Which effect is associated with the administration of narcotic pain medications?

Answer 41

Decreased level of consciousness | An effect of narcotic pain medication is a decrease in level of consciousness.

Question 42

Which findings indicate that a patient is experiencing an ototoxic effect?

Answer 42

Tinnitus Tinnitus, ringing in the ears, is an example of an ototoxic effect because the inner ear cochlea helps patients hear. Correct Hearing loss Hearing loss that may or may not be permanent is an example of an ototoxic effect. Correct Problems keeping balance Problems keeping balance is an example of an ototoxic effect because the inner ear semicircular canals help patients maintain balance. Correct Issues with equilibrium Issues with equilibrium is an example of an ototoxic effect because the inner ear semicircular canals help patients maintain balance.

Question 43

Which information by the nurse indicates a correct understanding of cognition or sensation?

Answer 43

Alertness is controlled by the reticular activating system in the brain. Alertness is controlled by the reticular activating system (RAS) located in the brain.

Question 44

Which effects would the nurse expect to find when caring for a patient who uses street drugs?

Answer 44

Dizziness Dizziness is an effect of street drug use. Correct Confusion Confusion is an effect of street drug use. Pupil size changes Street drugs can cause changes in pupil size.

Question 45

The patient has a health care provider prescription for NPO (nothing by mouth) and is complaining of a dry, sticky mouth. Which action would the nurse suggest to relieve the patient’s dry, sticky mouth?

Answer 45

Rinsing the mouth with water Mouth care for NPO patients includes rinsing the mouth with water. Brushing the teeth Brushing teeth is part of mouth care for NPO patients.

Question 46

Which foods should be avoided by a patient on a renal diet?

Answer 46

Foods high in potassium and phosphorus Foods high in potassium and phosphorus should be avoided on a renal diet. Potassium and phosphorus can build up in the bloodstream of these patients. Too much potassium in the bloodstream can cause heart issues; too much phosphorus can cause calcium to be pulled from bones

Question 47

diets

Answer 47

Foods with a high glycemic index should be avoided on a diabetic diet but are not of concern for renal diets. Foods high in potassium and phosphorus should be avoided on a renal diet. Potassium and phosphorus can build up in the bloodstream of these patients. Too much potassium in the bloodstream can cause heart issues; too much phosphorus can cause calcium to be pulled from bones. High-fiber foods do not need to be avoided on a renal diet. High-sodium foods should be avoided on a cardiac diet but are not of concern for renal diets.

Question 48

A patient who is borderline diabetic has expressed a desire to make lifestyle changes in an effort to avoid taking medications. Which dietary modification would be appropriate for this patient?

Answer 48

Eating high-fiber complex carbohydrates High-fiber complex carbohydrates from vegetables and fruits are preferred to simple carbohydrates, sugars, and starchy foods, such as bread or pie.

Question 49

The student nurse is providing feeding assistance to a patient at risk for aspiration. Which actions would the student nurse avoid?

Answer 49

Offering large bites to the patient Offering large bites may put a patient at risk for aspiration. Having the patient finish all foods, then drink all fluids Finishing all foods and then drinking all fluids may put a patient at risk for aspiration. Instead, foods and fluids should be alternated. Having the patient use a straw when drinking Using a straw when drinking may put a patient at risk for aspiration.

Question 50

Which statement by the nurse to a patient demonstrates culturally competent nutritional care?

Answer 50

“When you use the terms ‘hot’ or ‘cold’ to describe foods, you may not be talking about the temperature.” In some cultures, describing foods as “hot” or “cold” may be in relation to healing qualities, not temperature or spiciness. This clarifying statement by the nurse is an example of culturally competent nursing care.

Question 51

A patient does not eat meat or animal products of any kind. The nurse would instruct the patient about which nutritional deficiencies?

Answer 51

Vitamin B12 A vegan diet has the potential to be deficient in vitamin B12. Correct Iron A vegan diet has the potential to be deficient in iron. Zinc Zinc is a potential deficiency in a vegan diet.

Question 52

Which complications would the nurse monitor for in a patient receiving total parenteral nutrition (TPN)?

Answer 52

Catheter-related infections Catheter-related infections are considered a potential complication resulting from TPN. Site infections Site infections are considered a potential complication resulting from TPN; therefore, the nurse should perform a skin assessment prior to feeding.

Question 53

A patient who was placed on thickened liquids asks if there is something to eat that does not require a thickening agent. Which liquids or foods could be safely recommended?

Answer 53

Yogurt Yogurt is a food that could be safely recommended that does not require a thickening agent. Pudding Pudding can be safely recommended as a food that does not require a thickening agent.

Question 54

Which tasks are considered appropriate feeding assistance?

Answer 54

Opening a milk carton Opening a milk carton and other hard-to-open items is appropriate feeding assistance, due to possible muscle atrophy or immobility. Correct Setting up a meal tray Setting up a meal tray is appropriate feeding assistance. Spoon-feeding a patient the entire meal Spoon-feeding a patient is appropriate feeding assistance.

Question 55

Which type of feeding tube is placed into the patient’s stomach through one of the nares?

Answer 55

Nasogastric tube | A nasogastric tube is placed through the nares into the stomach.

Question 56

Which action would the nurse take to provide appropriate percutaneous endoscopic gastrostomy (PEG) tube care?

Answer 56

Assessing skin around the tube Assessing skin around the tube is considered appropriate PEG tube care because these sites have a potential for infection.

Question 57

The student nurse is educating the patient regarding signs and symptoms to report to the health care provider for at-home tube feedings. Which statement indicates the student needs further teaching?

Answer 57

“If you have a headache after a feeding, you should call your health care provider.” This is an incorrect statement, so the student nurse needs further teaching. A headache after feeding is not reportable to the health care provider.

Question 58

For which complications would a nurse monitor in a patient receiving total parenteral nutrition (TPN)?

Answer 58

Catheter-related bloodstream infection Catheter-related bloodstream infection is a potential complication related to TPN. Correct Site infection Site infection is a potential complication related to TPN. Occlusion of TPN tubing Occlusion of TPN tubing is a potential complication related to TPN. Correct Air embolism Air embolism is a potential complication related to TPN.

Question 59

The nurse is caring for an older adult with Alzheimer disease and a secondary diagnosis of malnutrition. Which neurologic functions affect the patient’s ability to receive adequate nutrition?

Answer 59

Functional ability Alzheimer disease is a neurologic disorder that affects functional ability. Alzheimer patients may not have the motor skills required to feed themselves. Correct Cognitive ability Alzheimer disease is a neurologic disorder that affects cognitive ability. Alzheimer patients may not have the cognitive skills required to feed themselves. Correct Memory Alzheimer disease is a neurologic disorder that affects memory. Alzheimer patients may not remember to eat.

Question 60

Which complications may result from malabsorption?

Answer 60

Poor wound healing Malabsorption may cause poor wound healing because the body will not have enough nutrients to heal properly. Weight loss Malabsorption may cause weight loss because the patient will not have absorbed enough calories to maintain weight. Correct Fatigue Malabsorption may cause fatigue because fewer nutrients will have been absorbed. The nutrients are not available to provide the patient with energy.

Question 61

A patient presents to the hospital with persistent bloody diarrhea, vomiting, and stomatitis. Laboratory values indicate the patient has suffered nutritional imbalance as a result of recent decreased food intake and diarrhea. Which inflammatory bowel disease could be responsible?

Answer 61

Crohn disease Stomatitis is inflammation of the mouth and lips. Crohn disease is a chronic disease that causes inflammation in any part of the gastrointestinal tract, including the mouth.

Question 62

diseases

Answer 62

Phenylketonuria (PKU) PKU is a rare condition in which an infant's body fails to metabolize the amino acid phenylalanine. Diverticular disease Diverticular disease is a condition where small pouches or sacs have formed in the colon wall. Stomatitis would not be a symptom. Crohn disease Stomatitis is inflammation of the mouth and lips. Crohn disease is a chronic disease that causes inflammation in any part of the gastrointestinal tract, including the mouth. Ulcerative colitis Ulcerative colitis causes ulcers in the large intestine only. Stomatitis would not be a symptom.

Question 63

The nurse weighs a 13-year-old female patient, asks her how she feels about her body, and collects data about the different types of foods she likes to eat during the day. Which type of assessment is the nurse performing?

Answer 63

health history A health history includes the type of foods a patient eats, the patient's body self-esteem, and physical symptoms the patient may be experiencing.

Question 64

A young patient is working with a nurse on nutrition improvement. The nurse tells the patient that there are two main ways to examine dietary habits. The nurse is referring to which two methods?

Answer 64

Food diary and 24-hour recall method The food diary and 24-hour recall method are two types of assessments the nurse can use to assess the amount and type of food a patient is consuming.

Question 65

A pediatric nurse working in a health care provider’s office has a well-child visit with a 5-year-old. Which anthropometric measurements will the nurse most likely take?

Answer 65

Height Height is a common anthropometric measurement for children. Correct Weight Weight is a common anthropometric measurement for children. Head circumference Head circumference is a common anthropometric measurement for children.

Question 66

Which physical assessment findings are strongly correlated with a patient's risk for obesity and heart disease?

Answer 66

Waist circumference Larger waist circumference is strongly associated with heart disease and can indicate obesity. Correct Body fat percentage Higher body fat percentage is strongly associated with nutritional status and health risk potential. Correct Body shape Body shapes with more fat around the waist have a higher risk for serious health problems.

Question 67

An unconscious patient is brought to the emergency department by ambulance. Initial assessment findings by the nurse and health care provider include skin that is dry and yellow in color, noticeable thinness, eyes set back in the head, and a strong odor of alcohol. Severe malnutrition from alcoholism is suspected. Which laboratory tests would the nurse expect to see prescribed for a nutrition assessment?

Answer 67

Blood glucose A blood glucose test would indicate the patient's current glucose level in the blood to determine if emergent intervention was necessary. Correct Albumin An albumin test assesses plasma protein level, which would most likely be very low in a severely malnourished alcoholic. Correct Blood urea nitrogen (BUN) and creatinine BUN and creatinine tests are indicators of kidney function and are important diagnostic tests for nutrition. Incorrect Complete blood count (CBC) A CBC is a generic test ordered frequently. It provides information for nutritional levels, anemia, infection, and infection.

Question 68

The nurse is caring for an older adult who lives alone. The nurse becomes concerned that the patient is getting inadequate nutrition based on which neurologic manifestations?

Answer 68

Decreased alertness Neurologic consequences of poor nutrition include decreased alertness. Correct Slower muscle response time Neurologic consequences of poor nutrition include slower muscle response time. Slower problem-solving Neurologic consequences of poor nutrition include slower problem-solving.

Question 69

An adult patient is being treated in the hospital for hypertensive crisis. Which nutritional modification should the patient make immediately that can positively impact blood pressure?

Answer 69

Decrease salt. | Decreasing sodium or salt intake will have a direct impact on hypertension.

Question 70

An athletic adolescent girl is being treated for iron deficiency anemia. Which symptoms are expected with this condition?

Answer 70

Fatigue Fatigue is a symptom of iron deficiency anemia. Dizziness Dizziness is a symptom of iron deficiency anemia. Correct Pale skin Pale skin is a symptom of iron deficiency anemia.

Question 71

A patient in the telemetry unit is recovering from a heart attack. The nurse teaches the patient that blood flow to part of the heart was occluded by plaque from which substances?

Answer 71

Cholesterol Cholesterol combines with other substances and attaches itself to the walls of the arteries. Correct Lipids Lipids combine with other substances and attach themselves to the walls of the arteries.

Question 72

Parents of an infant diagnosed with phenylketonuria (PKU) are informed that the condition is a result of failure to metabolize amino acids after consuming which substance?

Answer 72

Protein PKU is a rare condition in which an infant's body fails to metabolize the amino acid phenylalanine, and dangerous levels of phenylalanine build up after consuming protein.

Question 73

A high school nurse notes that girls on the cross-country team eat together each day. She notes that one of the girls only consumes an apple each day at lunch and has experienced a decline in her athletic performance. Which condition does the nurse suspect in this girl?

Answer 73

Anorexia nervosa | Anorexia nervosa is a serious eating disorder in which the person restricts dietary intake.

Question 74

The nurse is completing the physical assessment on a patient just admitted to the hospital. The nurse is focusing on the nutritional aspects of this assessment. Which factors should the nurse pay close attention to when examining the patient?

Answer 74

Skin, hair, and dentition | A patient’s skin, hair, and dentition can be strong indicators of nutritional status.

Question 75

A patient has been admitted to the hospital for malnutrition, and the nurse is explaining the plan of care. When the nurse comes in to take blood for the physical assessment, which statement is most appropriate for the nurse to make to the patient?

Answer 75

“A laboratory study will allow us as your health care providers to thoroughly assess your nutritional status.” This explanation conveys to the patient the importance of laboratory studies as part of a thorough nutritional assessment.“

Question 76

The nurse is focused on a 22-year-old male's need to weigh himself every day. The patient made a comment about how ugly he feels and said that for girls to like him he must be skinny. He told the nurse that he takes laxatives on a regular interval to help maintain his figure. Which information can the nurse determine from this assessment?

Answer 76

The patient has negative body self-esteem. | The patient's extreme focus on weight and dislike for his body indicate negative body self-esteem.

Question 77

A nurse is working on nutrition with a 64-year-old patient. The nurse asks the patient to describe the types and amounts of food consumed the previous day. Which type of assessment is the nurse completing?

Answer 77

24-hour recall The nurse is completing a 24-hour recall assessment, in which the patient is asked to recount the types and amounts of food consumed over the last day.

Question 78

A 14-year-old female is brought into the emergency department (ED) by her parents. She is 5’3” and weighs 75 pounds. Her parents state that she refuses to eat. Based upon this information, what can the nurse determine about the patient?

Answer 78

The patient might have an eating disorder. The patient's weight and refusal to eat may indicate an eating disorder; eating disorders are common in teenage children and must be evaluated for carefully.

Question 79

Which factors are included in the DETERMINE self-assessment of nutrition for older adults?

Answer 79

Multiple medications, involuntary weight loss, and tooth loss These three factors are components of the DETERMINE self-assessment.

Question 80

The nurse is using anthropometric measurements to assess a 46-year-old patient. The patient is below average in weight, waist circumference, and body mass index (BMI) for height. Which factor does the nurse need to consider in the assessment?

Answer 80

The patient is at risk for malnutrition. | With decreased measurements, the patient is not getting enough nutrition and is definitely at risk for malnutrition.

Question 81

Match the laboratory value to the corresponding description.

Answer 81

Indicates levels of energy-containing molecules -Blood glucose Identifies the level of oxygen-carrying capacity in the blood -Hemoglobin Determines level of kidney function -Blood urea nitrogen (BUN) and creatinine Indicates average blood glucose level for the past 2–3 months -Hemoglobin A1c

Question 82

A 25-year-old female patient is getting her annual physical. The medical assistant measures her waist at 40 inches. According to North American standards for waist circumference, the patient is at risk for which condition?

Answer 82

Heart disease Heart disease has been strongly correlated with a larger amount of fat stored around the waist. For women, waist circumference greater than 35 inches is considered at-risk.

Question 83

The primary nurse is advocating for a patient with a nursing hypothesis of Impaired Self-Feeding. With whom would the nurse collaborate to provide a cost-effective assistive feeding device for the patient?

Answer 83

Case manager | A case manager is responsible for providing cost-effective assistive feeding devices.

Question 84

Which primary pathophysiologic process would the nurse conclude is occurring in a patient who has a hypothesis of Impaired Self-Feeding?

Answer 84

Sensory and motor deficits secondary to spinal cord injury | Sensory and motor deficits secondary to spinal cord injury is a pathologic cause for Impaired Self-Feeding.

Question 85

An obese patient is asking for guidance to lose weight. Which hypothesis and patient-centered outcome would be the most appropriate related to nutrition for the patient?

Answer 85

Excess Food Intake resulting in obesity. Patient will identify factors related to obesity by the next clinic appointment. Excess Food Intake is an appropriate hypothesis for the patient, and it has a measurable, reasonable, patient-centered outcome.

Question 86

Which individuals would a nurse collaborate with in an attempt to obtain the best possible outcomes for a pediatric patient with anorexia and bulimia?

Answer 86

Patient, dietitian, psychologist, and case manager The patient, dietitian, psychologist, and case manager are the most appropriate multidisciplinary team to collaborate in attempt to attain the best possible patient outcomes.

Question 87

Which primary pathophysiologic process would the nurse conclude is occurring in a patient who has a hypothesis of Impaired Swallowing?

Answer 87

Residual effects of neurologic damage secondary to cerebrovascular accident Residual effects of neurologic damage secondary to a cerebrovascular accident is a pathologic cause for Impaired Swallowing.

Question 88

An underweight patient is asking for guidance to gain muscle weight. Which hypothesis and patient-centered outcome would be the most appropriate related to nutrition for the patient?

Answer 88

Deficient Food Intake resulting in low body weight. Patient will identify factors related to nutritional consumption by the next clinic appointment. Deficient Food Intake is an appropriate hypothesis for the patient, and it has a measurable, reasonable, and patient-centered outcome.

Question 89

In which areas would the nurse provide assistance for a patient who is blind and has mild aches?

Answer 89

Safety needs Blind patients need safe surroundings to minimize the risk for injury. Correct Eating assistance Blind patients may require assistance with meal preparation and eating by using a clock analogy. Correct Pain management Pain management is needed because the patient has mild aches. Activities of daily living Blind patients need assistance with activities of daily living because the hospital is not a familiar environment.

Question 90

In which ways would the nurse evaluate the effectiveness of interventions for patients with cognitive deficits?

Answer 90

Incorporating input from family members Sometimes the patient with cognitive deficits is too confused, so incorporating input from family members allows the nurse to evaluate the effectiveness of interventions for the patient. Correct Noting a decline in the patient’s condition Noting a decline in condition when the patient is cognitively impaired is an indication that the intervention is not effective and needs adjustment. Correct Observing for increased patient independence Increased independence is a goal that, when reached by the cognitively impaired patient, indicates that the intervention is successful.

Question 91

Which actions would the nurse take for a patient with severe vision loss and impaired verbal communication?

Answer 91

Placing the call light within reach Placing the call light within reach is an important safety measure for a patient with severe vision loss. Correct Orienting the patient to the room Orientation to furniture and equipment placement is an important safety measure for a patient with severe vision loss. Incorrect Speaking clearly without shouting Speaking clearly without shouting is appropriate for a patient with impaired verbal communication. Correct Using voice-recognition equipment Voice-recognition equipment is an important safety measure for a patient with severe vision loss.

Question 92

Which action would the nurse take for a confused patient who is found wandering in the street and is admitted to the emergency department for observation?

Answer 92

Take an oral temperature. The nurse would take an oral temperature to determine if an infection is causing the confusion or if something else is wrong.

Question 93

Which interventions would the nurse implement for a patient with an auditory deficit?

Answer 93

Reducing background noise The nurse would reduce background noise to make it easier for the patient with an auditory deficit to hear. Correct Keeping the hands away from the mouth The nurse would keep the hands away from the mouth so the patient can see to read lips. Ensuring that there is no cerumen in the hearing aid The nurse would ensure that there is no cerumen in the hearing aid so it can work properly to help the patient hear better.

Question 94

Which intervention would the nurse select to maintain safety for a patient with dementia who is uncooperative at times and exhibits negative behaviors toward other patients?

Answer 94

Looking at family photographs with the patient | Reminiscing about the past by looking at family photographs can calm and redirect negative behaviors.

Question 95

Which actions would the nurse take for a patient with sensory overload to relieve stress from family visits?

Answer 95

Reducing noise Reducing noise will relieve stress and sensory overload. Correct Blocking nursing care Blocking nursing care by grouping care that can be done together will limit overstimulation. Planning care around rest Planning care around rest will relieve stress and sensory overload.

Question 96

Which strategy would the nurse use to promote self-care for a patient who has memory impairment?

Answer 96

Providing assistance with hygiene | Assistance with hygiene is a strategy the nurse would use to promote self-care.

Question 97

Which general orientation considerations would the nurse use for a confused patient?

Answer 97

Involving the patient in concrete activities A general orientation consideration the nurse would use for a confused patient is to involve the patient in concrete activities such as folding towels. Providing reality orientation Providing reality orientation is a general orientation consideration the nurse would use for a confused patient. Correct Limiting the amount of gestures Limiting the amount of gestures is a general orientation consideration the nurse would use for a confused patient.

Question 98

Which intervention would the nurse implement for a patient with impaired socialization and sensory deprivation?

Answer 98

Encouraging the patient to play cards This action would be taken for a patient with impaired socialization because it encourages social interaction and would help lessen the sensory deprivation.

Question 99

Which strategy would the nurse use for a patient with a stable weight who continues to have gustatory and olfactory deficits?

Answer 99

Continuing to monitor the patient Since the weight is stable, the nurse would continue to monitor the patient with gustatory (taste) and olfactory (smell) deficits.

Question 100

Which safety precaution would the nurse discuss with a patient who has tactile alterations and is being discharged home?

Answer 100

Check the water heater settings. Checking the water heater setting is a safety precaution to discuss with a patient who has tactile (touch) alterations to prevent scalding or burning.

Question 101

Which finding would alert the nurse that a patient is experiencing a therapeutic effect from dimenhydrinate?

Answer 101

Vertigo is decreased. | Dimenhydrinate is a medication for motion sickness; thus, vertigo would be decreased.

Question 102

Which intervention would the nurse take for a patient who is squinting when attempting to walk to the bathroom?

Answer 102

Ask if glasses are worn at home. If the patient uses glasses at home, it is important to know and to encourage the patient to use them in the hospital for safety.

Question 103

Which actions would the nurse take for a patient with gustatory alterations?

Answer 103

Serving flavorful foods Serving flavorful foods will promote intake for a patient with gustatory (taste) alterations. Performing oral hygiene Performing oral hygiene is important to keep the oral cavity fresh and hydrated and to improve appetite in a patient with gustatory (taste) alterations.

Question 104

Which strategy would the nurse use for a patient who has been withdrawn and not interested in activities of daily living?

Answer 104

Provide audiobooks. Audiobooks engage the patient’s interest and would help the patient who is prone to sensory deprivation feel less isolated

Question 105

Which response would the nurse make to a patient who has an equilibrium deficit and does not want to walk at home because of fear of falling?

Answer 105

“Use a cane or a walker when you are ambulating.” | A cane or walker will provide the patient stability when ambulating and reduce the risk for a fall.

Question 106

Which self-care measure would the nurse prioritize for a patient with severe visual sensory deprivation?

Answer 106

Interacting socially A patient with severe visual sensory deprivation is at risk for social isolation, so planning social interaction is an important measure.

Question 107

When preparing a patient with cognitive alterations for discharge home, which safety topics would the nurse include for family education?

Answer 107

Use of door locks with keys Wandering is often a safety concern for cognitively impaired patients, so doors with key locks are prevention measures to use at home. Correct Avoidance of “why” questions Asking “why” questions can cause agitation in patients with cognitive alterations; thus, “why” questions should be avoided. Correct Supervision requirements Supervision requirements are addressed with the family for a patient with cognitive alterations. If 24-hour supervision and assistance with care are needed, the nurse and social services can make provisions with loved ones or a day care service.

Question 108

Which discharge instructions would the nurse share with a patient who has a visual deficit?

Answer 108

Remove throw rugs. Removing throw rugs is an appropriate intervention for a patient with a visual deficit to prevent falls. Install grab bars in the tub or shower. Installing grab bars in the tub or shower can help prevent falls from visual deficits when getting in and out of the tub or shower. Correct Provide bright lighting in the hallways. Bright lighting should be provided in darkened hallways to prevent injury and maintain independence in the home. Correct Move furniture so there are wide pathways. Widened pathways promote ambulation without bumping into furniture or causing a fall.

Question 109

Which response would the nurse make to a confused patient who is hearing voices that the food is poisoned?

Answer 109

“That must be scary, but I do not hear the voices.” | The nurse would respond with this statement to present reality and focus on the patient’s feelings.

Question 110

Which action would the nurse take if a patient who has delirium is still delirious after 4 days of treatment?

Answer 110

Asking the patient if any recreational drugs have been taken The nurse would try to determine why the patient is not improving, and recreational drugs may be a possibility for no improvement; delirium should start to improve after treatment.

Question 111

Which findings would alert the nurse that a patient with sensory overload is declining?

Answer 111

Is becoming overwhelmed A patient with sensory overload who is becoming overwhelmed is declining. Correct Is anxious A patient with sensory overload who is anxious is declining. Correct Inability to concentrate A patient with sensory overload who cannot concentrate is declining.

Question 112

Which vital sign results are correctly correlated to their unexpected cognitive findings?

Answer 112

Elevated temperature—confusion, disorientation Elevated temperature (fever) can lead to confusion and disorientation, which are unexpected cognitive findings. Correct Hypertension—headache Hypertension can lead to headache, which is an unexpected cognitive finding. Correct Orthostatic hypotension—dizziness Orthostatic hypotension can lead to dizziness, which is an unexpected cognitive finding. Correct Low pulse oximetry—restlessness Low pulse oximetry can lead to restlessness, which is an unexpected cognitive finding.

Question 113

Which parameter is the nurse primarily assessing using these images? clocks

Answer 113

Spatial orientation | The nurse is assessing spatial orientation by having the patient draw a clock.

Question 114

Which cues are expected with a patient who has Ménière disease?

Answer 114

Vertigo Vertigo, a spinning sensation, is a cue associated with Ménière disease. Correct Progressive hearing loss Hearing loss that is progressive occurs with Ménière disease. Tinnitus Tinnitus, ringing in the ears, is a cue associated with Ménière disease.

Question 115

Which laboratory data would the nurse monitor in an older adult patient who is confused and may have suffered a cerebrovascular accident (CVA)?

Answer 115

Electrolytes The nurse would monitor electrolytes for confusion because both elevated and low levels can lead to confusion. Blood glucose The nurse would monitor blood glucose levels because extremes in blood glucose can cause cognitive deficits such as confusion. Correct Cholesterol level The nurse would monitor cholesterol levels because high levels can lead to CVA. Correct Urinalysis The nurse would monitor the urinalysis because urinary tract infections can cause confusion in the older adult.

Question 116

Which cranial nerve is affected if the patient has anosmia?

Answer 116

I | Cranial nerve I (olfactory) is affected if the patient has anosmia, which is a decrease or loss of smell.

Question 117

Which cues are associated with Alzheimer disease?

Answer 117

Wandering Wandering is a cue for Alzheimer disease. Correct Sundowning Sundowning, which describes confusion/agitation in the late afternoon, evening, and even into the night, is a cue for Alzheimer disease. Correct Memory loss Memory loss is a cue for Alzheimer disease. Correct Repetitive behaviors Repetitive behaviors are cues for Alzheimer disease.

Question 118

Which cranial nerve is affected in sensorineural hearing loss?

Answer 118

VIII | Cranial nerve VIII (vestibulocochlear) is the nerve affected in sensorineural hearing loss.

Question 119

Which impairment is a patient with a recent cerebrovascular accident (CVA) experiencing when able to follow commands but has difficulty responding verbally?

Answer 119

Expressive aphasia In expressive aphasia, patients can follow commands because they understand what they hear. However, they have difficulty responding verbally because they cannot express words appropriately.

Question 120

Which cues would the nurse likely observe in a patient with a cerebrovascular accident (CVA)?

Answer 120

Elevated triglycerides Elevated triglycerides is a cue associated with CVA. Correct Aphasia Aphasia and speech difficulties are cues associated with CVA. Correct Motor deficits Motor deficits are a cue associated with CVA. Correct Brain infarct indicated on CT scan A CT scan indicating a brain infarct is a cue associated with CVA.

Question 121

Which eye condition is caused by an increase in intraocular pressure?

Answer 121

Glaucoma | Glaucoma is caused by increased intraocular pressure.

Question 122

Match each cognitive condition to its appropriate description.

Answer 122

General term for decreased oxygen to the brain causing ischemia - Ischemic stroke Clot or plaque preventing blood flow to the brain - Cerebrovascular accident Bleeding in the brain caused by a traumatic brain injury - Hemorrhagic stroke Difficulty with speech - Aphasia

Question 123

Which patient conditions can lead to conductive hearing loss?

Answer 123

Has excess cerumen buildup in ear Excess cerumen buildup in the ear can lead to conductive hearing loss because the ear wax blocks the sound waves. Correct Is diagnosed with otitis media Otitis media, an ear infection with fluid behind the eardrum, can lead to conductive hearing loss because the sound waves are blocked.

Question 124

Which hypothesis would the nurse select for a patient who is interpreting external stimuli incorrectly, can recall the medical history, and has a high blood alcohol level and abnormal electrolyte levels?

Answer 124

Delirium | The patient is experiencing Delirium from the high blood alcohol level and abnormal electrolyte levels.

Question 125

Which patient cues would prompt the nurse to select the hypothesis Impaired Balance?

Answer 125

Positive Romberg test A positive Romberg test is a cue for Impaired Balance because it is a test for equilibrium. Correct Vertigo Vertigo (a spinning sensation) is a cue for Impaired Balance. Medical diagnosis of Ménière disease A medical diagnosis of Ménière disease is a cue for Impaired Balance because it causes vertigo.

Question 126

Which hypotheses would the nurse develop for a patient who is recently confused, oriented × 1, speaking in fragmented sentences, has abnormal electrolytes, and when asked health history questions replies, “I don’t know”?

Answer 126

Delirium The nurse would develop this hypothesis because the patient has recent confusion and disorientation with abnormal electrolytes. Correct Acute Confusion The nurse would develop this hypothesis because the confusion is recent (acute). Impaired Memory The nurse would develop this hypothesis because the patient is exhibiting Impaired Memory by not being able to contribute information when asked questions about a health history. Correct Impaired Verbal Communication The nurse would develop this hypothesis because the patient is having difficulty with verbal communication, which is noted by the use of fragmented sentences.

Question 127

Match the hypothesis to its pathophysiologic cause. need to fix

Answer 127

``` Damaged insula - Delirium Damaged occipital lobe - Impaired Vision Progressive cerebrum deterioration - Chronic Confusion Cerebellum dysfunction - Impaired Balance ```

Question 128

Which multidisciplinary team members would the nurse collaborate with for a patient with a hypothesis of Impaired Sense of Smell?

Answer 128

Otolaryngologist An otolaryngologist is a health care provider that deals with ear, nose, and throat problems. Impaired Sense of Smell involves the nose, so the nurse would collaborate with this team member. Dietitian A dietitian would be needed to help with decreased food intake from the Impaired Sense of Smell.

Question 129

Which nursing-derived outcome relates directly to a patient who has damage to cranial nerve VIII?

Answer 129

Patient will not fall during hospitalization. Cranial nerve VIII (vestibulocochlear) is involved with balance; thus, this outcome would relate directly to this patient.

Question 130

Which outcomes would the nurse select for a patient who suddenly becomes disoriented × 3, is agitated, and is processing stimuli incorrectly from a high fever?

Answer 130

Patient will regain orientation × 3 before discharge. The nurse would select this outcome because the patient is delirious and will regain orientation because the condition is reversible. Correct Patient will not experience hallucinations for the next 48 hours. The nurse would select this outcome because the patient is delirious and processing stimuli incorrectly (hallucinating). Incorrect Patient will not injure self while hospitalized. The nurse would select this outcome because the patient is delirious and must be kept safe.

Question 131

Which hypothesis would the nurse develop for a patient with peripheral neuropathy?

Answer 131

``` Impaired Tactile Perception Peripheral neuropathy (tingling and numbness in extremities) is a cue for Impaired Tactile (touch) Perception. ```

Question 132

Which hypothesis would the nurse select for an older adult patient with presbycusis?

Answer 132

Impaired Hearing | Presbycusis is age-related hearing loss; thus, Impaired Hearing is appropriate for this patient.

Question 133

Which hypothesis would the nurse select for an older adult patient who has dementia, continues to be confused and disoriented, and wanders the halls at night?

Answer 133

Chronic Confusion The nurse would select Chronic Confusion because the patient has dementia (a chronic disorder) and continues with the confusion, disorientation, and wandering.

Question 134

Which patient situations would require the nurse to immediately intervene?

Answer 134

Becomes restless and confused The nurse would immediately intervene if the patient is restless and confused; this is a safety issue. Correct Has a sudden loss of peripheral vision The nurse would immediately intervene if the patient has a sudden loss of peripheral vision; this can cause permanent blindness.

Question 135

Which outcome would the nurse develop for a patient with the hypothesis Acute Confusion?

Answer 135

Patient will respond appropriately to questions within 24 hours. The nurse would develop this outcome for Acute Confusion because it relates to confusion and is measurable.

Question 136

For which patient hypotheses would the nurse consider reorientation measures as a solution?

Answer 136

Chronic Confusion Reorientation measures are appropriate solutions for Chronic Confusion. Correct Delirium Reorientation measures are appropriate solutions for Delirium to help with confusion and disorientation. Impaired Memory Reorientation measures are appropriate solutions for Impaired Memory.

Question 137

Which outcomes would the nurse develop for a patient who has a damaged vestibulocochlear cranial nerve?

Answer 137

Patient will not fall during hospitalization. Balance (thus falls) is regulated by the vestibulocochlear cranial nerve, so the nurse would select this outcome. Correct Patient will slowly rise every time from a sitting position. Balance/equilibrium is regulated by the vestibulocochlear cranial nerve; thus, the nurse would select this outcome. Patient will hear a whispered word with the use of a hearing aid before discharge. Hearing is regulated by the vestibulocochlear cranial nerve; thus, the nurse would select this outcome.

Question 138

Which overall goal would the nurse develop for a patient with permanent damage to the optic cranial nerve?

Answer 138

Promote independence in performing activities of daily living (ADLs) The optic cranial nerve is involved with vision; thus, the overall goal is to promote independence in performing ADLs.

Question 139

Which solutions would the nurse consider for a patient with Impaired Socialization resulting from aphasia?

Answer 139

Mental health services Mental health services would be a solution for this patient to help with feelings related to social interaction. Correct Speech therapy Speech therapy would be a solution because the patient has aphasia (speech and language problems). Correct Texting Texting would be a solution because the patient has speech problems (aphasia). Therapeutic communication techniques Therapeutic communication techniques would be a solution to support the patient.

Question 140

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority.

Answer 140

Patient who is experiencing profuse bleeding from a fall Patient who becomes delirious Patient who has chronic confusion Patient who has social isolation

Question 141

Which outcome would the nurse develop for a patient with a hypothesis of Chronic Confusion?

Answer 141

Patient will not wander to other units while hospitalized. The nurse would select this outcome for a patient with Chronic Confusion because it is directly related to mental functioning that is deteriorating.

Question 142

1. The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.)

Answer 142

2. Sepsis 3. Hemorrhage 4. Skin breakdown

Question 143

2. The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.)

Answer 143

1. Serum total protein 5 Serum BUN

Question 144

3. The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention?

Answer 144

4. Stop feeding her.

Question 145

4. A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse’s priority action?

Answer 145

1. Have the patient turn on the left side and perform a Valsalva maneuver.

Question 146

5. A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition?

Answer 146

4. When 75% of the patient’s nutritional needs are met by the tube feedings

Question 147

6. A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention?

Answer 147

3. Continue the feedings; this is normal gastric residual for this feeding.

Question 148

7. Which action can a nurse delegate to assistive personnel (AP)?

Answer 148

1. Performing glucose monitoring every 6 hours on a patient

Question 149

8. Which statement made by the parents of a 2-month-old infant requires further education by the nurse?

Answer 149

4. “I’m going to alternate formula with whole milk, starting next month.”

Question 150

9. A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse?

Answer 150

2. Placing client supine while giving a bath

Question 151

10. A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.)

Answer 151

1. Change the dressing using sterile technique. | 3. Change the TPN tubing every 24 hours.