Chapter 05: Adult Health and Nutritional Assessment
Hinkle: Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 13th Edition
MULTIPLE CHOICE
1. A school nurse is teaching a 14-year-old girl of normal weight some of the key
factors necessary to maintain good nutrition in this stage of her growth and
development. What interventions should the nurse most likely prioritize?
A) Decreasing her calorie intake and encouraging her to maintain her weight to avoid
obesity
B) Increasing her BMI, taking a multivitamin, and discussing body image
C) Increasing calcium intake, eating a balanced diet, and discussing eating disorders
D) Obtaining a food diary along with providing close monitoring for anorexia
ANS: C
Adolescent girls are considered to be at high risk for nutritional disorders.
Increasing calcium intake and promoting a balanced diet will provide the
necessary vitamins and minerals. If adolescents are diagnosed with eating
disorders early, the recovery chances are increased. The question presents no
information that indicates a need for decreasing her calories. There is no
apparent need for an increase in BMI. A food diary is used for assessing eating
habits, but the question asks for teaching factors related to good nutrition.
2. A nurse is conducting a health assessment of an adult patient when the patient
asks, why do you need all this health information and who is going to see it?
What is the nurse's best response?
A) Please do not worry. It is safe and will be used only to help us
with your care. It's accessible to a wide variety of people who
are invested in your health.
B) It is good you asked and you have a right to know; your information
helps us to provide you with the best possible care, and your records
are in a secure place.
, C) Your health information is placed on secure Web sites to provide
easy access to anyone wishing to see your medical records. This
ensures continuity of care.
D) Health information becomes the property of the hospital and we will
make sure that no one sees it. Then, in 2 years, we destroy all records
and the process starts over.
ANS: B
Whenever information is elicited from a person through a health history or
physical examination, the person has the right to know why the information is
sought and how it will be used. For this reason, it is important to explain what
the history and physical examination are, how the information will be obtained,
and how it will be used. Medical records allow access to health care providers
who need the information to provide patients with the best possible care, and the
records are always held in a secure environment. Telling the patient not to
worry minimizes the patient's concern regarding the safety of his or her health
information and a wide variety of people should not have access to patients'
health information. Health information should not be placed on Web sites and
health records are not destroyed every 2 years.
3. The nurse is performing an admission assessment of a 72-year-old female
patient who understands minimal English. An interpreter who speaks the
patient's language is unavailable and no members of the care team speak the
language. How should the nurse best perform data collection?
A) Have a family member provide the data.
B) Obtain the data from the old chart and physician's assessment.
C) Obtain the data only from the patient, prioritizing aspects that the patient
understands.
D) Collect all possible data from the patient and have the family
supplement missing details.
, ANS: D
The informant, or the person providing the information, may not always be the
patient. The nurse can gain information from the patient and have the family
provide any missing details. The nurse should always obtain as much
information as possible directly from the patient. In this case, it is not likely
possible to get all the information needed only from the patient.
4. You are the nurse assessing a 28-year-old woman who has presented to the
emergency department with vague complaints of malaise. You note bruising to
the patient's upper arm that correspond to the outline of fingers as well as
yellow bruising around her left eye. The patient makes minimal eye contact
during the assessment. How might you best inquire about the bruising?
A) Is anyone physically hurting you?
B) Tell me about your relationships.
C) Do you want to see a social worker?
D) Is there something you want to tell me?
ANS: A
Few patients will discuss the topic of abuse unless they are directly asked.
Therefore, it is important to ask direct questions, such as, Is anyone physically
hurting you? The other options are incorrect because they are not the best way to
illicit information about possible abuse in a direct and appropriate manner.
5. You are the nurse performing a health assessment of an adult male patient. The
man states, The doctor has already asked me all these questions. Why are you
asking them all over again? What is your best response?
A) This history helps us determine what your needs may be for nursing care.
B) You are right; this may seem redundant and I'm sure that it's frustrating for you.
C) I want to make sure your doctor has covered everything that's
important for your treatment.
D) I am a member of your health care team and we want to make
Hinkle: Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 13th Edition
MULTIPLE CHOICE
1. A school nurse is teaching a 14-year-old girl of normal weight some of the key
factors necessary to maintain good nutrition in this stage of her growth and
development. What interventions should the nurse most likely prioritize?
A) Decreasing her calorie intake and encouraging her to maintain her weight to avoid
obesity
B) Increasing her BMI, taking a multivitamin, and discussing body image
C) Increasing calcium intake, eating a balanced diet, and discussing eating disorders
D) Obtaining a food diary along with providing close monitoring for anorexia
ANS: C
Adolescent girls are considered to be at high risk for nutritional disorders.
Increasing calcium intake and promoting a balanced diet will provide the
necessary vitamins and minerals. If adolescents are diagnosed with eating
disorders early, the recovery chances are increased. The question presents no
information that indicates a need for decreasing her calories. There is no
apparent need for an increase in BMI. A food diary is used for assessing eating
habits, but the question asks for teaching factors related to good nutrition.
2. A nurse is conducting a health assessment of an adult patient when the patient
asks, why do you need all this health information and who is going to see it?
What is the nurse's best response?
A) Please do not worry. It is safe and will be used only to help us
with your care. It's accessible to a wide variety of people who
are invested in your health.
B) It is good you asked and you have a right to know; your information
helps us to provide you with the best possible care, and your records
are in a secure place.
, C) Your health information is placed on secure Web sites to provide
easy access to anyone wishing to see your medical records. This
ensures continuity of care.
D) Health information becomes the property of the hospital and we will
make sure that no one sees it. Then, in 2 years, we destroy all records
and the process starts over.
ANS: B
Whenever information is elicited from a person through a health history or
physical examination, the person has the right to know why the information is
sought and how it will be used. For this reason, it is important to explain what
the history and physical examination are, how the information will be obtained,
and how it will be used. Medical records allow access to health care providers
who need the information to provide patients with the best possible care, and the
records are always held in a secure environment. Telling the patient not to
worry minimizes the patient's concern regarding the safety of his or her health
information and a wide variety of people should not have access to patients'
health information. Health information should not be placed on Web sites and
health records are not destroyed every 2 years.
3. The nurse is performing an admission assessment of a 72-year-old female
patient who understands minimal English. An interpreter who speaks the
patient's language is unavailable and no members of the care team speak the
language. How should the nurse best perform data collection?
A) Have a family member provide the data.
B) Obtain the data from the old chart and physician's assessment.
C) Obtain the data only from the patient, prioritizing aspects that the patient
understands.
D) Collect all possible data from the patient and have the family
supplement missing details.
, ANS: D
The informant, or the person providing the information, may not always be the
patient. The nurse can gain information from the patient and have the family
provide any missing details. The nurse should always obtain as much
information as possible directly from the patient. In this case, it is not likely
possible to get all the information needed only from the patient.
4. You are the nurse assessing a 28-year-old woman who has presented to the
emergency department with vague complaints of malaise. You note bruising to
the patient's upper arm that correspond to the outline of fingers as well as
yellow bruising around her left eye. The patient makes minimal eye contact
during the assessment. How might you best inquire about the bruising?
A) Is anyone physically hurting you?
B) Tell me about your relationships.
C) Do you want to see a social worker?
D) Is there something you want to tell me?
ANS: A
Few patients will discuss the topic of abuse unless they are directly asked.
Therefore, it is important to ask direct questions, such as, Is anyone physically
hurting you? The other options are incorrect because they are not the best way to
illicit information about possible abuse in a direct and appropriate manner.
5. You are the nurse performing a health assessment of an adult male patient. The
man states, The doctor has already asked me all these questions. Why are you
asking them all over again? What is your best response?
A) This history helps us determine what your needs may be for nursing care.
B) You are right; this may seem redundant and I'm sure that it's frustrating for you.
C) I want to make sure your doctor has covered everything that's
important for your treatment.
D) I am a member of your health care team and we want to make
