HEALTH ASSESSMENT EXAM 2: STUDY
GUIDE WITH COMPLETE SOLUTION
Chapter 08:
1. The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-
hip ratios. Which one of these patients would be at increased risk?
A. 29-year-old woman whose waist measures 33 inches and hips measure 36 inches
B. 32-year-old man whose waist measures 34 inches and hips measure 36 inches
C. 38-year-old man whose waist measures 35 inches and hips measure 38 inches
D. 46-year-old woman whose waist measures 30 inches and hips measure 38 inches
Answer: A
The waist-to-hip ratio assesses body fat distribution as an indicator of health risk. A waist-to-hip
ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of android (upper body
obesity) and increasing risk for obesity-related disease and early death. The 29-year-old woman
has a waist-to-hip ratio of 0.92, which is greater than 0.8. The 32-year-old man has a waist-to-
hip ratio of 0.94; the 38-year-old man has a waist-to- hip ratio of 0.92; the 46-year-old woman
has a waist-to-hip ratio of 0.78.
2. A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the
clinic to find out about her laboratory results. What would be important for the nurse to include
in patient teaching in relation to these tests?
A. The risks of undernutrition should be included.
B. Offer methods to reduce the stress in her life.
C. Provide information regarding a diet low in saturated fat.
D. This condition is hereditary; she can do nothing to change the levels.
Answer: C
,The patient with elevated cholesterol and triglyceride levels should be taught about eating a
healthy diet that limits the intake of foods high in saturated fats or trans fats. Reducing dietary
fats is part of the treatment for this condition. The other responses are not pertinent to her
condition.
3. 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
Answer: B
Dysphagia, or impaired swallowing, interferes with adequate nutrient intake.
4. 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
Answer: B
Kwashiorkor (protein malnutrition) is due to diets that may be high in calories but contain little
or no protein (e.g., low-protein liquid diets, fad diets, and long-term use of dextrose- containing
intravenous fluids). The serum albumin would be less than 3.5 g/dl.
5. 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.
Answer: A
Normal physiologic changes in aging adults that affect nutritional status include slowed
gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste
sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.
6. 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
Answer: C
Important nutritional features of the older years are a decrease in energy requirements as a
result of loss of lean body mass, the most metabolically active tissue, and an increase in fat
mass.
7. 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
Answer: C
, Food diaries require the individual to write down everything consumed for a certain time
period. Because of the erratic eating patterns of this individual, assessing dietary intake over a
few days would produce more accurate information regarding eating patterns.
Direct observation is best used with young children or older adults.
1. When performing a physical assessment, the first technique the nurse will always use is:
A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.
Answer: b
The skills requisite for the physical examination are inspection, palpation, percussion, and
auscultation. The skills are performed one at a time and in this order (with the exception of the
abdominal assessment, during which auscultation takes place before palpation and percussion).
The assessment of each body system begins with inspection. A focused inspection takes time
and yields a surprising amount of information.
2. The nurse is preparing to perform a physical assessment. Which statement is true about
the physical assessment? The inspection phase:
A. Usually yields little information.
B. Takes time and reveals a surprising amount of information.
C. May be somewhat uncomfortable for the expert practitioner.
D. Requires a quick glance at the patient’s body systems before proceeding with palpation.
Answer: b
A focused inspection takes time and yields a surprising amount of information. Initially, the
examiner may feel uncomfortable, staring at the person without also doing something. A
focused assessment is significantly more than a “quick glance.”
3. The nurse is assessing a patient’s skin during an office visit. What part of the hand and
technique should be used to best assess the patient’s skin temperature?
GUIDE WITH COMPLETE SOLUTION
Chapter 08:
1. The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-
hip ratios. Which one of these patients would be at increased risk?
A. 29-year-old woman whose waist measures 33 inches and hips measure 36 inches
B. 32-year-old man whose waist measures 34 inches and hips measure 36 inches
C. 38-year-old man whose waist measures 35 inches and hips measure 38 inches
D. 46-year-old woman whose waist measures 30 inches and hips measure 38 inches
Answer: A
The waist-to-hip ratio assesses body fat distribution as an indicator of health risk. A waist-to-hip
ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of android (upper body
obesity) and increasing risk for obesity-related disease and early death. The 29-year-old woman
has a waist-to-hip ratio of 0.92, which is greater than 0.8. The 32-year-old man has a waist-to-
hip ratio of 0.94; the 38-year-old man has a waist-to- hip ratio of 0.92; the 46-year-old woman
has a waist-to-hip ratio of 0.78.
2. A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the
clinic to find out about her laboratory results. What would be important for the nurse to include
in patient teaching in relation to these tests?
A. The risks of undernutrition should be included.
B. Offer methods to reduce the stress in her life.
C. Provide information regarding a diet low in saturated fat.
D. This condition is hereditary; she can do nothing to change the levels.
Answer: C
,The patient with elevated cholesterol and triglyceride levels should be taught about eating a
healthy diet that limits the intake of foods high in saturated fats or trans fats. Reducing dietary
fats is part of the treatment for this condition. The other responses are not pertinent to her
condition.
3. 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
Answer: B
Dysphagia, or impaired swallowing, interferes with adequate nutrient intake.
4. 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
Answer: B
Kwashiorkor (protein malnutrition) is due to diets that may be high in calories but contain little
or no protein (e.g., low-protein liquid diets, fad diets, and long-term use of dextrose- containing
intravenous fluids). The serum albumin would be less than 3.5 g/dl.
5. 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.
Answer: A
Normal physiologic changes in aging adults that affect nutritional status include slowed
gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste
sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.
6. 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
Answer: C
Important nutritional features of the older years are a decrease in energy requirements as a
result of loss of lean body mass, the most metabolically active tissue, and an increase in fat
mass.
7. 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
Answer: C
, Food diaries require the individual to write down everything consumed for a certain time
period. Because of the erratic eating patterns of this individual, assessing dietary intake over a
few days would produce more accurate information regarding eating patterns.
Direct observation is best used with young children or older adults.
1. When performing a physical assessment, the first technique the nurse will always use is:
A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.
Answer: b
The skills requisite for the physical examination are inspection, palpation, percussion, and
auscultation. The skills are performed one at a time and in this order (with the exception of the
abdominal assessment, during which auscultation takes place before palpation and percussion).
The assessment of each body system begins with inspection. A focused inspection takes time
and yields a surprising amount of information.
2. The nurse is preparing to perform a physical assessment. Which statement is true about
the physical assessment? The inspection phase:
A. Usually yields little information.
B. Takes time and reveals a surprising amount of information.
C. May be somewhat uncomfortable for the expert practitioner.
D. Requires a quick glance at the patient’s body systems before proceeding with palpation.
Answer: b
A focused inspection takes time and yields a surprising amount of information. Initially, the
examiner may feel uncomfortable, staring at the person without also doing something. A
focused assessment is significantly more than a “quick glance.”
3. The nurse is assessing a patient’s skin during an office visit. What part of the hand and
technique should be used to best assess the patient’s skin temperature?
