EXAM 1 (OVER CHS 1,2,3,4,8,9)
CH 1
The nurse is doing admission assessments on four new clients. Mrs. S is a postoperative client. Mrs. X is
an 84-year-old who lives alone and tries to eat a heart-healthy diet. Mr. Y was admitted from a long-term
care facility because of muscle wasting and swollen neck glands. Mr. Z is a 35-year-old who is a
postoperative hernia client. Which client would be referred to the dietitian because of suspected
protein-energy malnutrition?
The moderate- to high-risk clients with suspected or confirmed protein-energy malnutrition
While doing admission assessments, the nurse finds that Mrs. S does not drink; Mrs. X enjoys a glass of
wine at supper and bedtime; Mr. Y has been drinking at least a six-pack of beer every day for the past 20
years and has been ordered by his doctor; and Mr. Z has a cocktail when he goes out to dinner, which is
about once a month. Which clients would be considered at nutritional risk?
Mrs. X and Mr. Y
The nurse is caring for a client for whom serum albumin screening has been used to assess protein
status. The nurse understands that there are disadvantages to using albumin to indicate the nutritional
status of protein in the body. What is one of those disadvantages?
It is not specific for nutritional status.
When doing a diet screening on a client, the nurse tries to use terms other than "diet" when asking
about the foods the client eats. Which term is not an alternative term to the word "diet"?
Counting calories
Unintentional weight loss can be an indicator of malnutrition; however, apparent weight gain may be an
unreliable indicator of improvement due to which of the following?
Anasarca
,Research done on increasing the effectiveness of client teaching has found that the type of nutritional
counseling that is most effective is that done by whom?
Nurses and dietitians
A 77-year-old client who lives alone is admitted to the hospital after his children found him in a confused
state at home. It is uncertain whether or not he has been eating correctly. As the nurse is preparing the
nursing care plan, which of the following nursing diagnoses would indicate nutrition intervention is
appropriate?
Self-care deficit: feeding
A 47-year-old, obese female client is admitted for hypertensive crisis. During the assessment, she states
she has tried every diet out there and she is not interested in trying another one. She refuses to talk with
the dietitian. Which of the following is the best approach for the nurse to use to help this client?
Emphasize things "to do" instead of "not to do"
The nurse is admitting a 35-year-old client with alcoholism to the hospital. In planning nursing care, what
long-term nutritional goals might the nurse set?
To improve eating habits to reduce the risk of chronic disease
When educating the client, the nurse understands that there can be some negativity associated with the
term "diet". Many clients may view "diet" as another term for which of the following?
A short-term punishment to endure
Nursing care plans include nursing diagnoses that have nutritional significance when the nurse assesses
it as being necessary. If the nurse is writing a nursing care plan for a client with an obvious nutritional
deficiency, which nursing diagnosis would be most appropriate to include?
,Imbalanced nutrition: less than body requirements
To ensure all inpatients receive adequate care, The Joint Commission specifies that nutrition screening
be conducted at what time during hospital admission?
Within 24 hours after admission
The nurse is admitting a client who is diagnosed with type 2 diabetes mellitus. While in the hospital, the
client has a referral to see a bariatric surgeon for evaluation for gastric surgery. The bariatric surgeon
writes an order for a body mass index (BMI) to be calculated. The nurse understands that a BMI is which
of the following?
A calculation of an index of a person's weight in relation to height
The nurse is finishing an admission assessment for Mrs. M who was admitted during a previous shift.
While doing the medical psychosocial history, the following facts come to light: Two years ago, she was
treated for a major depressive episode; she practices Islam; she lives in the area of town where there are
many Muslim people; and she comes from a wealthy family. Her hair is visibly dry and dull, and she
mentions that her hand grip has gotten weaker over the last few months. Because of the findings during
this assessment, the nurse decides to refer her to the dietitian for a nutrition assessment. What in the
medical psychosocial assessment might lead to a nutritional deficiency?
She has had a major depressive episode.
A client is admitted with persistent diarrhea and a weight loss of 10 pounds. What would the nurse
recognize as the significance of the weight loss if the client stated that he had lost the weight over the
past 3 months?
Signifies a chronic versus acute condition
A nursing student is taking a course in geriatric nursing, and the subject for today is altered nutritional
status. The instructor lectures about older adults not eating in a healthy manner due to factors such as
limited income, inability to prepare cooked meals, or inability to shop due to lack of transportation.
What factor in the physical assessment would indicate to the nurse that the older adult client might be
malnourished?
, Poor wound healing
A client who was widowed 6 weeks ago had had a depressed appetite since his wife died. He admits to
not eating very much and says his appetite gets worse as the day goes on. He has unintentionally lost 19
pounds since his wife's death and complains of around-the-clock fatigue. He is admitted to the unit for
weight loss due to inadequate nutritional intake. What nursing intervention would be appropriate for the
nurse to include in the care plan for this client?
Encourage the client to eat a big breakfast.
A nurse is attending a conference on "Nutrition and Nursing." One of the subjects being covered is "How
to Facilitate Client and Family Nutritional Teaching." The nurse returns to the unit and shares several
suggestions on nutritional teaching for clients and families with other members of the staff. Which of the
following is an appropriate suggestion for teaching?
Listen to the client's concerns and ideas.
Monitoring and evaluation of nursing goals and outcomes are integral parts of the nursing process. A
nurse working on a very busy unit feels she does not have adequate time to monitor clients' nutritional
intakes or to ensure they are meeting their established outcomes. What is a simple nursing intervention
that can assist the nurse in evaluating clients' intended outcomes?
Have the client weighted daily and record the weight.
During a nutrition screening, an 84-year-old client tells the nurse he really likes ice cream. He goes on to
say that, when he was growing up, his grandfather used to give him ice cream when he hurt himself in
any way. He also says that his mother would give him homemade chicken soup when he was sick. One of
the admission diagnoses for this client is minor depression with mood swings. In planning his meals,
what would be appropriate for the nurse to include?
Foods that are considered "comfort foods"
CH 1
The nurse is doing admission assessments on four new clients. Mrs. S is a postoperative client. Mrs. X is
an 84-year-old who lives alone and tries to eat a heart-healthy diet. Mr. Y was admitted from a long-term
care facility because of muscle wasting and swollen neck glands. Mr. Z is a 35-year-old who is a
postoperative hernia client. Which client would be referred to the dietitian because of suspected
protein-energy malnutrition?
The moderate- to high-risk clients with suspected or confirmed protein-energy malnutrition
While doing admission assessments, the nurse finds that Mrs. S does not drink; Mrs. X enjoys a glass of
wine at supper and bedtime; Mr. Y has been drinking at least a six-pack of beer every day for the past 20
years and has been ordered by his doctor; and Mr. Z has a cocktail when he goes out to dinner, which is
about once a month. Which clients would be considered at nutritional risk?
Mrs. X and Mr. Y
The nurse is caring for a client for whom serum albumin screening has been used to assess protein
status. The nurse understands that there are disadvantages to using albumin to indicate the nutritional
status of protein in the body. What is one of those disadvantages?
It is not specific for nutritional status.
When doing a diet screening on a client, the nurse tries to use terms other than "diet" when asking
about the foods the client eats. Which term is not an alternative term to the word "diet"?
Counting calories
Unintentional weight loss can be an indicator of malnutrition; however, apparent weight gain may be an
unreliable indicator of improvement due to which of the following?
Anasarca
,Research done on increasing the effectiveness of client teaching has found that the type of nutritional
counseling that is most effective is that done by whom?
Nurses and dietitians
A 77-year-old client who lives alone is admitted to the hospital after his children found him in a confused
state at home. It is uncertain whether or not he has been eating correctly. As the nurse is preparing the
nursing care plan, which of the following nursing diagnoses would indicate nutrition intervention is
appropriate?
Self-care deficit: feeding
A 47-year-old, obese female client is admitted for hypertensive crisis. During the assessment, she states
she has tried every diet out there and she is not interested in trying another one. She refuses to talk with
the dietitian. Which of the following is the best approach for the nurse to use to help this client?
Emphasize things "to do" instead of "not to do"
The nurse is admitting a 35-year-old client with alcoholism to the hospital. In planning nursing care, what
long-term nutritional goals might the nurse set?
To improve eating habits to reduce the risk of chronic disease
When educating the client, the nurse understands that there can be some negativity associated with the
term "diet". Many clients may view "diet" as another term for which of the following?
A short-term punishment to endure
Nursing care plans include nursing diagnoses that have nutritional significance when the nurse assesses
it as being necessary. If the nurse is writing a nursing care plan for a client with an obvious nutritional
deficiency, which nursing diagnosis would be most appropriate to include?
,Imbalanced nutrition: less than body requirements
To ensure all inpatients receive adequate care, The Joint Commission specifies that nutrition screening
be conducted at what time during hospital admission?
Within 24 hours after admission
The nurse is admitting a client who is diagnosed with type 2 diabetes mellitus. While in the hospital, the
client has a referral to see a bariatric surgeon for evaluation for gastric surgery. The bariatric surgeon
writes an order for a body mass index (BMI) to be calculated. The nurse understands that a BMI is which
of the following?
A calculation of an index of a person's weight in relation to height
The nurse is finishing an admission assessment for Mrs. M who was admitted during a previous shift.
While doing the medical psychosocial history, the following facts come to light: Two years ago, she was
treated for a major depressive episode; she practices Islam; she lives in the area of town where there are
many Muslim people; and she comes from a wealthy family. Her hair is visibly dry and dull, and she
mentions that her hand grip has gotten weaker over the last few months. Because of the findings during
this assessment, the nurse decides to refer her to the dietitian for a nutrition assessment. What in the
medical psychosocial assessment might lead to a nutritional deficiency?
She has had a major depressive episode.
A client is admitted with persistent diarrhea and a weight loss of 10 pounds. What would the nurse
recognize as the significance of the weight loss if the client stated that he had lost the weight over the
past 3 months?
Signifies a chronic versus acute condition
A nursing student is taking a course in geriatric nursing, and the subject for today is altered nutritional
status. The instructor lectures about older adults not eating in a healthy manner due to factors such as
limited income, inability to prepare cooked meals, or inability to shop due to lack of transportation.
What factor in the physical assessment would indicate to the nurse that the older adult client might be
malnourished?
, Poor wound healing
A client who was widowed 6 weeks ago had had a depressed appetite since his wife died. He admits to
not eating very much and says his appetite gets worse as the day goes on. He has unintentionally lost 19
pounds since his wife's death and complains of around-the-clock fatigue. He is admitted to the unit for
weight loss due to inadequate nutritional intake. What nursing intervention would be appropriate for the
nurse to include in the care plan for this client?
Encourage the client to eat a big breakfast.
A nurse is attending a conference on "Nutrition and Nursing." One of the subjects being covered is "How
to Facilitate Client and Family Nutritional Teaching." The nurse returns to the unit and shares several
suggestions on nutritional teaching for clients and families with other members of the staff. Which of the
following is an appropriate suggestion for teaching?
Listen to the client's concerns and ideas.
Monitoring and evaluation of nursing goals and outcomes are integral parts of the nursing process. A
nurse working on a very busy unit feels she does not have adequate time to monitor clients' nutritional
intakes or to ensure they are meeting their established outcomes. What is a simple nursing intervention
that can assist the nurse in evaluating clients' intended outcomes?
Have the client weighted daily and record the weight.
During a nutrition screening, an 84-year-old client tells the nurse he really likes ice cream. He goes on to
say that, when he was growing up, his grandfather used to give him ice cream when he hurt himself in
any way. He also says that his mother would give him homemade chicken soup when he was sick. One of
the admission diagnoses for this client is minor depression with mood swings. In planning his meals,
what would be appropriate for the nurse to include?
Foods that are considered "comfort foods"
