Health Asses 15

An older adult patient has presented to the emergency department with signs and symptoms of dehydration. When assessing the patient for risk factors that may have contributed to this condition, what question should the nurse prioritize? • ìDo you use any over-the-counter dietary supplements?î • ìAre you familiar with the USDA's MyPlate recommendations?î • ìHave you ever been diagnosed with heart disease?î • ìAre you currently taking any diuretic medications?î • An older adult patient has a body mass index of 15.5 and is consequently considered to be underweight. The patient lives alone and states that she has ìnever been a heavy eater.î How can the nurse most accurately assess the patient's nutritional habits? • Assess the patient's waist circumference and waist-to-hip ratio. • Measure the patient's mid-arm circumference. • Elicit the patient's 24-hour food recall. • Have the patient describe an ìidealî meal. • During a new patient's nutritional assessment, the nurse asks the patient's height and usual weight. The patient states that he has no idea how much he weighs. How should the nurse respond? • ìDo you feel like your weight has increased, decreased, or stayed the same lately?î • ìWhy do you feel that it's not important to monitor your weight?î • ìIn a typical day, what do you eat and drink?î • ìHow would you describe your feelings around your body type and body mass?î • A hospital nurse is performing a nutritional assessment of a 39-year-old obese patient who has been recently diagnosed with type 2 diabetes. The nurse has completed the collection of subjective data and is preparing to proceed with objective data collection. Which principle should guide the nurse's subsequent actions? • There are likely to be inconsistencies between subjective data and objective data. • The nurse should be aware that the patient may find assessment embarrassing. • The nurse should avoid performing anthropometric measurements due to the patient's obesity. • The assessment should be performed over a series of brief sessions rather than one continuous assessment. • During an initial prenatal visit, the nurse is performing a nutritional assessment of a woman who has just learned that she is pregnant for the first time. The nurse has determined that the patient has an average stature and is 5 feet, 3 inches tall. What is this patient's ideal body weight? • 105 lbs. • 115 lbs. • 125 lbs. • 135 lbs. • A patient's recent complaints of polyuria have prompted a full diagnostic work-up for diabetes mellitus, including a nutritional assessment. To determine the patient's body mass index (BMI), the nurse must know which of the following assessment parameters? Select all that apply. • Gender • Age • Weight • Waist circumference • Height • The nurse is completing a comprehensive nutritional assessment and has assessed and documented the patient's triceps skin fold thickness (TSF) using calipers. This assessment finding allows the nurse to determine which of the following? • The patient's ratio of muscle to adipose tissue • The patient's body mass index • The patient's proportion of muscle mass • The amount of the patient's subcutaneous fat stores • A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. The nurse has lowered the patient's arm and observed how long it takes for venous filling, then raised the same arm and watched how long it takes to empty. After determining that venous filling and emptying each take approximately 10 seconds, the nurse should perform further assessments related to what health problem? • Fluid volume deficit • Third spacing • Ascites • Malnutrition • The nurse is providing care for a patient with a history of chronic heart failure. The patient is in bed with the head of her bed at 45 degrees, and the nurse is assessing the patient's neck veins. What assessment finding would be most consistent with a nursing diagnosis of fluid volume excess related to chronic heart failure? • The patient's carotid arteries are not palpable. • The patient's jugular veins are clearly visible and firm to palpation. • The patient's carotid pulses are asymmetrical and difficult to palpate. • The patient's carotid pulses are easier to palpate than the jugular pulses. • An obese teenage boy from a culture that values increased body mass has been referred to the clinic. The nurse is assessing him for malnutrition based on his electronic health record and current health complaints. His mother questions the nurse's rationale, stating, ìAnyone can see he's not malnourished. Just look at the size of him!î How should the nurse best respond? • ìPeople sometimes become obese because their bodies are storing up nutrients that they often lack.î • ìIt's actually very possible for a person to be overweight but have inadequate nutrition.î ìAssessment for malnutrition is a standard component of a larger nutritional assessment, which is very important for your son's health.î • ìActually, there's very little relationship between body mass and nutritional state.î The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. During health promotion, the nurse should focus education on which of the following topics? • Management of dry skin • Susceptibility to bruising • Risks of fungal infections • Risks of sun exposure • The nurse is performing an assessment of a patient admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis? • Nail beds • Sclerae • Palms • Oral mucosa • A 45-year-old African-American patient comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following should the nurse do next? • Document the benign findings. • Perform a random blood sugar test. • Ask the patient about a family history of cancer. • Refer the patient for medical follow-up. • An older adult female patient is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the patient based on the understanding that dry skin is normal with aging due to a decrease of what? • Squamous cells • Sweat glands • Subcutaneous tissue • Sebum production • The nurse's assessment of an adult female patient reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system? • Endocrine • Neurologic • Cardiovascular • Genitourinary • During an integumentary assessment, the nurse notes that the patient's fingernails are very thin and concave. The nurse knows the patient needs medical follow-up for further assessment to rule out which condition? • Diabetes mellitus • Iron deficiency anemia • Vitamin A deficiency • Peripheral vascular disease • In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds? • Psoriasis • Multiple sclerosis • Malignant melanoma • Peripheral vascular disease • A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer? • Stage I • Stage II • Stage III • Stage IV • A 15-year-old boy shows the school nurse a ìbumpî on his neck. The nurse observes a raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the presence of which of the following? • Macule • Papule • Nodule • Pustule • While inspecting the skin of an older adult patient, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? • Purpura • Petechiae • Ecchymosis • Cherry angioma • A patient has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. During assessment using the mnemonic ABCDE, which finding would the nurse identify as being most suggestive of melanoma? • Solid, dark brown color • Asymmetric, irregular borders • Diameter of 3 mm • Flat with silvery scales • An older adult patient reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess? • Papule • Vesicle • Bulla • Crust • The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a patient who complains of an ìitching rash.î Which question would be most important for the nurse to ask? • ìAre you allergic to foods, medications, or other substances?î • ìDoes anyone else in your family have a rash like this?î • ìHow painful is your rash?î • ìWhat have you been doing to control the itching?î • A patient's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the patient's skin to have what characteristic? • Increased thickness and hair loss • Increased thinness • Pallor • Erythema • An older adult male patient states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess? • Integumentary • Digestive • Neurologic • Circulatory • Assessment of a patient's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies? • Fungal infection • Bacterial infection • Circulatory disorder