Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment med-surg

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 growth and development. What

interventions should the nurse prioritize to the client?

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

C

The nurse is performing an admission assessment of a client with minimal

understanding of the dominant language. An interpreter who speaks the client's language

is unavailable and no members of the care team speak the language. How will the nurse

best perform data collection?

A. Have a family member provide the data.

B. Obtain the data from the old chart and health care provider's assessment.

C. Obtain the data only from the client.

D. Collect all possible data from the client and wait for a health facility interpreter.

D

The nurse is assessing a 28-year-old client who has presented to the emergency

department with vague reports of malaise. The nurse observes bruising to the client's

upper arm that corresponds to the outline of fingers as well as yellow bruising around the

left eye. The client makes minimal eye contact during the assessment. How should the

nurse 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?"

A

The nurse is taking a health history on an adult client who is new to the clinic. The

client states that the client's mother has type 1 diabetes. What is the primary significance

of this information to the health history?

A. The client may be at risk for developing diabetes.

B. The client may need teaching on the effects of diabetes.

C. The client may need to attend a support group for individuals with diabetes.

D. The client may benefit from a dietary regimen that tracks glucose intake.

A

A nurse is performing the admission assessment of a client who will be treated for

pancreatitis on the medical unit. During the nursing assessment, the nurse asks the client

questions related to the client's spirituality. The primary rationale for this aspect of the

nurse's assessment is that the client's spiritual environment can affect which area of life?

A. Physical activity

B. Ability to communicate

C. Quality of sexual relationships

D. Response to illness

D

The school nurse is working with a high school junior whose body mass index (BMI) is

31. When working collaboratively with the client on the care plan, the nurse should

propose which goal?

A. Continuation of current diet and activity level

B. Increase in exercise and reduction in calorie intake

C. Possible referral to an eating disorder clinic

D. Increase in daily calorie intake

B

A home care nurse is teaching meal planning to a client's adult child who is caring for

the client during recovery from hip replacement surgery. Which daily menus suggested

by the client's child indicates a correct understanding of proper nutrition, based on the

U.S. Department of Agriculture's MyPlate?

A. Cheeseburger, carrot sticks, and mushroom soup with whole wheat crackers

B. Spaghetti and meat sauce with garlic bread and a salad

C. Chicken and pepper stir fry on a bed of rice

D. Ham sandwich with tomato on rye bread with peaches and yogurt

D

The nurse is assessing a 76-year-old client who has presented with an unintended

weight loss of 10 lb over the past 8 weeks. During the assessment, the nurse learns that

the client has ill-fitting dentures and a limited intake of high-fiber foods. What other

health problem is the client at risk to develop?

A. Constipation

B. Deficient fluid volume

C. Infection

D. Excessive intake of convenience foods

A

The nurse is teaching a nutrition education class for a group of older adults at a senior

center. When planning this education, the nurse should be aware that individuals at this

point in the lifespan have which of the following?

A. A decreased need for calcium

B. An increased need for glucose

C. An increased need for sodium

D. A decreased need for calories

D

The emergency department nurse is obtaining a health history from a client who

reported experiencing intermittent abdominal pain. Which question should the nurse ask

to elicit the probable reason for the visit and identify the client's chief issue?

A. "Why do you think your abdomen is painful?"

B. "Where exactly is your abdominal pain and when did it start?"

C. "What brings you to the hospital today?"

D. "What is wrong with you today?"

C

The nurse is caring for a client who identifies as Native American/First Nations. The

client arrives at the clinic for treatment related to type 2 diabetes. Which question would

best provide information about the role of food in the client's cultural practices and

identify how the client's food preferences could be related to the current condition?

A. "Do you feel any of your cultural practices have a negative impact on your

disease process?"

B. "What types of foods are served as a part of your cultural practices, and how are

they prepared?"

C. "As a non-Native, I am unaware of your cultural practices. Could you teach me

a few practices that may affect your care?"

D. "Tell me about foods that you eat and how you feel they influence managing

your diabetes."

D

A 30-year-old client is in the clinic for a yearly physical. The client states, "I found out

that two of my uncles had heart attacks when they were young." This alerts the nurse to

complete a genetic-specific assessment. In addition to a complete health history, which

components should the nurse include in this assessment?

A. A genogram along with any history of cholesterol testing or screening and a

complete physical exam

B. A complete physical exam with an emphasis on genetic abnormalities

C. A focused physical exam followed by safety-related education

D. A family history focused on the paternal family with focused physical exam and

genetic profile

A

The school nurse is performing a sports physical on a healthy adolescent girl who is

planning to try out for the volleyball team. When it comes time to listen to the student's

heart and lungs, what is the best nursing action?

A. Perform auscultation with the stethoscope placed firmly over the clothing to

protect the client's privacy.

B. Perform auscultation by holding the diaphragm lightly on the client's clothing to

eliminate the "scratchy noise".

C. Perform auscultation with the diaphragm placed firmly on the client's skin to

minimize extra noise.

D. Defer the exam because the girl is known to be healthy and chest auscultation

may cause anxiety.

C

A nurse who provides care in a campus medical clinic is performing an assessment of

a 21-year-old student who has presented for care. After assessment, the nurse

determines that the client has a body mass index (BMI) of 45. What does this indicate?

A. The client is of normal weight.

B. The client is extremely obese.

C. The client is overweight.

D. The client is mildly obese.

B

A nurse is conducting a home visit as part of the community health assessment of a

client who will receive scheduled wound care. During assessment, the nurse should

prioritize what variable(s)?

A. Availability of home health care, current government subsidies, and family

support

B. The community and home environment, support systems or family care, and the

availability of needed resources

C. The future health status of the individual, and community and hospital resources

D. The characteristics of the neighborhood, and the client's socioeconomic status

and insurance coverage

B

The nurse is performing a health history on a client. Which question will the nurse ask

to elicit information about past health history?

A. "Have you ever had surgery?"

B. "What brought you to the hospital today?"

C. "How is the health of your parents?"

D. "Are you in any pain?"

A

The nurse is admitting a 75-year-old client who is accompanied by a spouse. The

spouse wants to know where the information being obtained is going to be kept, and the

nurse describes the system of electronic health records. The spouse states, "I sure am

not comfortable with that. It is too easy for someone to break into computer records

these days." What is the nurse's best response?

A. "The government has called for the implementation of the computerized health

record so all hospitals are doing it."

B. "We've been doing this for several years with good success, so I can assure you

that our records are very safe."

C. "This hospital is concerned about keeping our clients' records private, so we take

special precautions to prevent unauthorized access."

D. "Your spouse's records will be safe, because only people who work in the

hospital have the credentials to access them."

C

A family whose religion limits the use of some forms of technology is admitting their

grandparent to the nurse's unit. They express skepticism about the fact that the nurse is

recording the admission data on a laptop computer. What would be the nurse's best

response to their concerns?

A. "It's been found that using computers improves our clients' care and improves

communication."

B. "We have found that it is easier to keep track of our clients' information this way

rather than with pen and paper."

C. "You'll find that all the hospitals are doing this now, and that writing information

with a pen is rare."

D. "The government is telling us we have to do this, even though most people, like

yourselves, are opposed to it."

A

The nurse is performing a dietary assessment with a client who has been admitted to

the medical unit with community-acquired pneumonia. The client asks if the nurse is

posing so many questions about the client's dietary practices because the client is from

another country. What is the nurse's best response to this client?

A. "We always try to abide by foreign-born clients' dietary preferences to make

them comfortable."

B. "We know that some cultural and religious practices include dietary guidelines,

and we do not want to violate these."

C. "We wouldn't want to feed you anything you only eat on certain holidays."

D. "We know that clients who grew up in other countries often have unusual diets,

and we want to accommodate this."

B

In the course of performing an admission assessment, the nurse has asked questions

about the client's first- and second-order relatives. What is the primary rationale for the

nurse's line of questioning?

A. To determine how many living relatives the client has

B. To identify the family's level of health literacy

C. To identify potential sources of social support

D. To identify diseases that may be genetic

D

The nurse is completing a family history for a client who is admitted for exacerbation

of chronic obstructive pulmonary disease (COPD). The nurse should include questions

that address which health problem? Select all that apply.

A. Allergies

B. Alcohol use disorder

C. Fractures

D. Hypervitaminosis

E. Obesity

A,B,E

Which action would the nurse perform during the inspection phase of the physical

examination?

A. Gather as many psychosocial details as possible by questioning the client.

B. Pay attention to the details while visually observing the client.

C. Document the client's breath sounds.

D. Avoid letting the client know that the client is being assessed.

B

During a comprehensive health assessment, which structure can the nurse best

assess by palpation?

A. Brain

B. Heart

C. Thyroid gland

D. Lungs

C

A 51-year-old client's recent reports of fatigue are thought to be caused by

iron-deficiency anemia. The client undergoes testing of the transferrin levels. This

biochemical assessment would be performed by assessing which type of specimen?

A. Urine

B. Serum

C. Cerebrospinal fluid (CSF)

D. Synovial fluid

B

A school nurse at a middle school is planning a health promotion initiative for girls.

The nurse has identified a need for nutritional teaching. What problem is most likely to

relate to nutritional problems in girls of this age?

A. Protein intake in this age group often falls below recommended levels.

B. Total calorie intake is often insufficient at this age.

C. Calcium intake is above the recommended levels.

D. Folate intake is below the recommended levels in this age group.

D

A team of community health nurses has partnered with the staff at a youth drop-in

center to address some of the nutritional needs of adolescents. Which situation most

often occurs during the adolescent years?

A. Lifelong eating habits are acquired.

B. Peer pressure influences growth.

C. BMI is determined.

D. Culture begins to influence diet.

A

A nurse who has practiced in the hospital setting for several years will now transition

to a new role in the community. How does a physical assessment in the community

compare with that in the hospital?

A. It consists of largely the same techniques.

B. It does not require privacy.

C. It is less comfortable for the client.

D. It is less structured.

A

The nurse is conducting an assessment of a client in the client's home. The client is 91

years old, lives alone, and has no family members living close by. What should the nurse

be aware of to aid in providing care to this client?

A. Where the closest relative lives

B. What resources are available to the client

C. What the client's financial status is

D. How many children the client has

B

What is the nurse's rationale for prioritizing biochemical assessment when appraising

a client's nutritional status?

A. It identifies abnormalities in the chemical structure of nutrients.

B. It predicts abnormal utilization of nutrients.

C. It reflects the tissue level of a given nutrient.

D. It predicts metabolic abnormalities in nutritional intake.

C

The nurse is providing care for a client who has several missing teeth. What is the

most likely nutritional consequence the nurse should anticipate for this client?

A. Inadequate intake of high-fiber foods

B. Inadequate caloric intake

C. Loss of fluid

D. Malabsorption of nutrients

A

When caring for a client who predominantly identifies with another culture than the

nurse, how can the nurse best demonstrate an awareness of culturally congruent care?

A. Maintain eye contact at all times.

B. Try to speak the client's primary language.

C. Use touch when communicating.

D. Establish effective communication.

D

The nurse is preparing a discharge teaching session with a client to evaluate the

client's ability to change a dressing. The client speaks and understands the dominant

language only minimally. What would be the best way to promote understanding during

the teaching session?

A. Ask the client to repeat the instructions carefully.

B. Write the procedure out for the client in simple language.

C. Use an interpreter during the teaching session.

D. Have the client demonstrate the dressing change.

C

The nurse is admitting a client with uncontrolled hypertension and type 1 diabetes to

the unit. During the initial assessment, the client reports seeking assistance and care

from the shaman in the client's community. What is the nurse's best response to the

client's indication that the care provider is a shaman?

A. "Thank you for providing the information about the shaman, but we will keep

that information and approach separate from your current hospitalization."

B. "It seems that the care provided by your shaman is not adequately managing

your hypertension and diabetes, so we will try researched medical approaches."

C. "Don't worry about insulting your shaman; the health care provider will explain

to the shaman that the shaman's approach to your hypertension and diabetes was

not working."

D. "I understand that you value the care provided by the shaman, but we would like

you to consider medications and dietary change

D

The nurse is performing a cultural nursing assessment of a newly admitted client.

What should the nurse include in the assessment? Select all that apply.

A. Family structure

B. Subgroups

C. Cultural beliefs

D. Health practices

E. Values

A c d e

The quality improvement team at the hospital has recognized the need to better

integrate the principles of transcultural nursing into client care. When explaining the

concept of transcultural nursing to uninitiated nurses, how should the team members

describe it?

A. The comparative analysis of the health benefits and risks of recognizable ethnic

groups

B. Research-focused practice that focuses on client-centered, culturally competent

nursing

C. A systematic and evidence-based effort to improve health outcomes in clients

who are immigrants

D. Interventions that seek to address language barriers in nursing practice

B

During an orientation class, the medical unit's nursing educator is presenting

education on transcultural nursing to a group of newly licensed nurses. What should the

staff educator identify as the underlying focus of transcultural nursing?

A. To enhance the cultural environment of institutions

B. To promote the health of communities

C. To provide culture-specific and culture-universal care

D. To promote the well-being of discrete, marginalized groups

C

The future of transcultural nursing care lies in finding ways to promote cultural

competence in nursing students. How can this goal be best accomplished?

A. By offering multicultural health studies in nursing curricula

B. By enhancing the content of community nursing classes

C. By requiring students to care primarily for clients from other ethnic groups

D. By screening applicants according to their cultural competence

A

Computed tomography of a 72-year-old client reveals lung cancer with metastasis to

the liver. The client's adult child has been adamant that any "bad news" be withheld from

the client to protect the client from stress, stating that this is a priority in their family's

culture. How should the nurse and the other members of the care team best respond?

A. Explain to the adult child the team's ethical obligation to inform the client.

B. Refer the family to social work.

C. Have a nurse or health care provider from the client's culture make contact with

the client and adult child.

D. Speak with the child to explore the rationale and attempt to reach a consensus.

D