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Health Assess 15

A nurse should conduct an assessment of a patient's Risk for Complications after gathering data related to the patient's spirituality. When planning the patient's care, the nurse should be aware that complications are primarily due to the effect of spirituality on what phenomenon? • Stress • Pain • Worry • Emotional lability • During a patient's spiritual assessment, the patient explains that the ultimate purpose of her existence is to achieve a state that she describes as nirvana. The nurse should recognize that this patient ascribes to what religion? • Islam • Hinduism • Buddhism • Judaism • A patient expresses frustration that the nurse is assessing his spirituality, stating, “I thought I was here to have my tumor removed, not to figure out what I believe or don't believe about God.” How should the nurse best justify the need for a spiritual assessment? • “It's important that we plan to make sure that we don't offend you.” • “Spirituality actually has a significant effect on your overall health.” • “We need to make plans in case there are unexpected outcomes of your surgery.” • “Your beliefs determine whether we will focus more on your body or on your spirit.” • The nurse's assessment of a hospital patient's spirituality reveals that the patient will accept very few of the standard treatments for her health problems. How should the nurse follow up this assessment finding? • Report the finding to the appropriate supervisors. • Prioritize complementary interventions in the patient's care. • Consult the patient's clergy to weigh options. • Document the patient's nonadherence to treatment. • The nurse is assessing a patient's spiritual history using the SPIRIT acronym. The nurse should begin the assessment by identifying what aspect of spirituality? • The patient's religious affiliation • The patient's state of health • The patient's sources of hope • The patient's spiritual belief system Assessment of a patient reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. Which of the following nursing diagnoses would be the nurse's priority? • Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination • Imbalanced nutrition: more than body requirements related to diabetes • Potential complication: hypertension • Powerlessness related to diabetes self-care and management • The nurse's assessment reveals that a patient is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate? • Teaching the patient muscle-building exercises • Discussing ways to increase body fat stores • Assisting patient in reducing the amount of fluid build-up • Encouraging the use of a multivitamin supplement • An adult patient weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the patient's body mass index is which of the following? • 12 • 18 • 25 • 28 • A patient weighs 106 pounds and is 5 feet 5 inches tall. As a result, her ideal body weight is 120 pounds. After determining the patient's percentage of ideal body weight, which of the following should the nurse conclude? • patient is mildly malnourished. • patient is experiencing moderate malnutrition. • Severe malnutrition is present. • The patient's body weight is within 10% of ideal body weight. • A nurse is reviewing the laboratory test results of an adult patient who has numerous chronic health challenges. Which assessment result would alert the nurse to potential malnutrition? • Hemoglobin of 13.1 g/dL • Hematocrit of 40% • Serum albumin of 2.6 g/dL • Total protein of 7 g/dL • The nurse should prioritize assessments related to overhydration for a patient experiencing which of the following health problems? • Early congestive heart failure • Chronic emphysema • Newly diagnosed hepatitis C virus infection • Adult respiratory distress syndrome l • The nurse is assessing a patient who has been admitted with signs and symptoms that are consistent with malnutrition. Which of the following physiological phenomena would the nurse recognize as an early indicator of malnutrition? • Protein stores are lower than normal • Bone is metabolized to compensate for missing nutrients • Calcium levels decrease • Hemoglobin levels decrease • A patient is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. Which of the following conclusions is suggested if the patient has no reaction? • It indicates high cholesterol and triglyceride levels. • It shows a sacrifice of skeletal muscle proteins and blood proteins. • It is indicative of unhealthy dietary habits. • It may be immunosuppression resulting from undernourishment. • The nurse is preparing to perform a nutritional assessment of a newly admitted patient. Which of the following questions would be most appropriate to use when initiating the assessment? • ìDid you eat breakfast today?î • ìHow many meals do you eat each day?î • ìCan you tell me what you've eaten in the last 24 hours?î • ìHow often do you eat out?î • A nurse is assessing a patient's skeletal muscle mass in the context of a comprehensive nutritional assessment. Which measurement would yield the most valid and reliable data? • Body mass index • Triceps skin fold measurement • Mid-arm circumference • Waist circumference • When evaluating nutrition in an adult female patient, which laboratory value would most concern the nurse? • Hemoglobin A1c of 9% • Serum albumin of 4.9 g/dL • Total protein of 6.7 g/dL • Hematocrit of 39% • A nurse weighs a patient today and finds that the patient's weight has increased 2.2 lbs from the previous day. The nurse interprets this finding as suggesting a fluid gain of which amount? • 0.5 liters • 1.0 liters • 1.5 liters • 2.0 liters • The nurse analyzes the data obtained from a patient's nutritional assessment and develops a health promotion diagnosis related to nutrition for a patient. Which of the following would be the best example? • Health-seeking behaviors related to desire and request to alter amount of food intake • Imbalanced nutrition: less than body requirements related to inadequate caloric intake • Imbalanced nutrition: more than body requirements related to excessive caloric intake • Ineffective thermoregulation related to decreased adaptability to cold secondary to decreased subcutaneous tissue • The nurse is collecting data from a patient about his nutrition. Which of the following would the nurse document as objective data? • patient states he is not eating well. • patient complains of nausea and vomiting. • patients experiences urinary frequency. • Tenting of patient's skin observed upon skin pinch. • A nurse in the intensive care unit is calculating an acutely ill patient's 24-hour fluid balance. The nurse should include insensible fluid losses of what volume when performing this assessment? • 100 to 300 mL • 450 to 650 mL • 800 to 1000 mL • 1200 to 1400 mL • A nurse is assessing a patient for possible fluid overload. Which of the following assessment findings is most consistent with this diagnosis? • Venous filling of 3 seconds • Distended neck veins with head elevated at 45 degrees • Moist, plump tongue • Boggy eyeball • During a nutritional assessment, the patient asks the nurse for suggestions to improve her diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to desire to improve diet. Which of the following suggestions would be most appropriate? • ìThe majority of your diet should consist of whole grains.î • ìChoose low-fat versions of milk products such as yogurt.î • ìDrink at least 2 to 3 glasses of fruit juices a day.î • ìEat fewer orange vegetables and more dark green vegetables daily.î • A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status? • Flat, firm abdomen • Brittle hair • Pink mucous membranes • Elastic skin • When obtaining the nutritional health history from a female patient, which of the nurse's questions would best elicit information about the patient's knowledge of her own health status? • ìAre you now or have you been on a diet recently?î • ìHow much fluid do you drink in a day?î • ìWhat are your height and usual weight?î • ìCan you tell me what you consider to be a healthy meal?î • The nurse needs to obtain the height of a patient who is unable to stand. Which of the following would the nurse do? • Estimate the height while the patient is lying in bed. • Measure the distance from the top of the patient's head to his ankles. • Measure from patient's arm span using one of his arms outstretched. • Extend a ruler from the forehead to the tip of the patient's toes.

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Health Assess 15

A nurse should conduct an assessment of a patient's Risk for Complications after gathering data related to the patient's spirituality. When planning the patient's care, the nurse should be aware that complications are primarily due to the effect of spirituality on what phenomenon? • Stress • Pain • Worry • Emotional lability • During a patient's spiritual assessment, the patient explains that the ultimate purpose of her existence is to achieve a state that she describes as nirvana. The nurse should recognize that this patient ascribes to what religion? • Islam • Hinduism • Buddhism • Judaism • A patient expresses frustration that the nurse is assessing his spirituality, stating, “I thought I was here to have my tumor removed, not to figure out what I believe or don't believe about God.” How should the nurse best justify the need for a spiritual assessment? • “It's important that we plan to make sure that we don't offend you.” • “Spirituality actually has a significant effect on your overall health.” • “We need to make plans in case there are unexpected outcomes of your surgery.” • “Your beliefs determine whether we will focus more on your body or on your spirit.” • The nurse's assessment of a hospital patient's spirituality reveals that the patient will accept very few of the standard treatments for her health problems. How should the nurse follow up this assessment finding? • Report the finding to the appropriate supervisors. • Prioritize complementary interventions in the patient's care. • Consult the patient's clergy to weigh options. • Document the patient's nonadherence to treatment. • The nurse is assessing a patient's spiritual history using the SPIRIT acronym. The nurse should begin the assessment by identifying what aspect of spirituality? • The patient's religious affiliation • The patient's state of health • The patient's sources of hope • The patient's spiritual belief system Assessment of a patient reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. Which of the following nursing diagnoses would be the nurse's priority? • Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination • Imbalanced nutrition: more than body requirements related to diabetes • Potential complication: hypertension • Powerlessness related to diabetes self-care and management • The nurse's assessment reveals that a patient is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate? • Teaching the patient muscle-building exercises • Discussing ways to increase body fat stores • Assisting patient in reducing the amount of fluid build-up • Encouraging the use of a multivitamin supplement • An adult patient weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the patient's body mass index is which of the following? • 12 • 18 • 25 • 28 • A patient weighs 106 pounds and is 5 feet 5 inches tall. As a result, her ideal body weight is 120 pounds. After determining the patient's percentage of ideal body weight, which of the following should the nurse conclude? • patient is mildly malnourished. • patient is experiencing moderate malnutrition. • Severe malnutrition is present. • The patient's body weight is within 10% of ideal body weight. • A nurse is reviewing the laboratory test results of an adult patient who has numerous chronic health challenges. Which assessment result would alert the nurse to potential malnutrition? • Hemoglobin of 13.1 g/dL • Hematocrit of 40% • Serum albumin of 2.6 g/dL • Total protein of 7 g/dL • The nurse should prioritize assessments related to overhydration for a patient experiencing which of the following health problems? • Early congestive heart failure • Chronic emphysema • Newly diagnosed hepatitis C virus infection • Adult respiratory distress syndrome l • The nurse is assessing a patient who has been admitted with signs and symptoms that are consistent with malnutrition. Which of the following physiological phenomena would the nurse recognize as an early indicator of malnutrition? • Protein stores are lower than normal • Bone is metabolized to compensate for missing nutrients • Calcium levels decrease • Hemoglobin levels decrease • A patient is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. Which of the following conclusions is suggested if the patient has no reaction? • It indicates high cholesterol and triglyceride levels. • It shows a sacrifice of skeletal muscle proteins and blood proteins. • It is indicative of unhealthy dietary habits. • It may be immunosuppression resulting from undernourishment. • The nurse is preparing to perform a nutritional assessment of a newly admitted patient. Which of the following questions would be most appropriate to use when initiating the assessment? • ìDid you eat breakfast today?î • ìHow many meals do you eat each day?î • ìCan you tell me what you've eaten in the last 24 hours?î • ìHow often do you eat out?î • A nurse is assessing a patient's skeletal muscle mass in the context of a comprehensive nutritional assessment. Which measurement would yield the most valid and reliable data? • Body mass index • Triceps skin fold measurement • Mid-arm circumference • Waist circumference • When evaluating nutrition in an adult female patient, which laboratory value would most concern the nurse? • Hemoglobin A1c of 9% • Serum albumin of 4.9 g/dL • Total protein of 6.7 g/dL • Hematocrit of 39% • A nurse weighs a patient today and finds that the patient's weight has increased 2.2 lbs from the previous day. The nurse interprets this finding as suggesting a fluid gain of which amount? • 0.5 liters • 1.0 liters • 1.5 liters • 2.0 liters • The nurse analyzes the data obtained from a patient's nutritional assessment and develops a health promotion diagnosis related to nutrition for a patient. Which of the following would be the best example? • Health-seeking behaviors related to desire and request to alter amount of food intake • Imbalanced nutrition: less than body requirements related to inadequate caloric intake • Imbalanced nutrition: more than body requirements related to excessive caloric intake • Ineffective thermoregulation related to decreased adaptability to cold secondary to decreased subcutaneous tissue • The nurse is collecting data from a patient about his nutrition. Which of the following would the nurse document as objective data? • patient states he is not eating well. • patient complains of nausea and vomiting. • patients experiences urinary frequency. • Tenting of patient's skin observed upon skin pinch. • A nurse in the intensive care unit is calculating an acutely ill patient's 24-hour fluid balance. The nurse should include insensible fluid losses of what volume when performing this assessment? • 100 to 300 mL • 450 to 650 mL • 800 to 1000 mL • 1200 to 1400 mL • A nurse is assessing a patient for possible fluid overload. Which of the following assessment findings is most consistent with this diagnosis? • Venous filling of 3 seconds • Distended neck veins with head elevated at 45 degrees • Moist, plump tongue • Boggy eyeball • During a nutritional assessment, the patient asks the nurse for suggestions to improve her diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to desire to improve diet. Which of the following suggestions would be most appropriate? • ìThe majority of your diet should consist of whole grains.î • ìChoose low-fat versions of milk products such as yogurt.î • ìDrink at least 2 to 3 glasses of fruit juices a day.î • ìEat fewer orange vegetables and more dark green vegetables daily.î • A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status? • Flat, firm abdomen • Brittle hair • Pink mucous membranes • Elastic skin • When obtaining the nutritional health history from a female patient, which of the nurse's questions would best elicit information about the patient's knowledge of her own health status? • ìAre you now or have you been on a diet recently?î • ìHow much fluid do you drink in a day?î • ìWhat are your height and usual weight?î • ìCan you tell me what you consider to be a healthy meal?î • The nurse needs to obtain the height of a patient who is unable to stand. Which of the following would the nurse do? • Estimate the height while the patient is lying in bed. • Measure the distance from the top of the patient's head to his ankles. • Measure from patient's arm span using one of his arms outstretched. • Extend a ruler from the forehead to the tip of the patient's toes.

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