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Chapter 5: Adult Health & Nutritional Assessment – Questions With Complete Solutions
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Chapter 5: Adult Health & Nutritional Assessment –Questions With Complete Solutions
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 her growth
and development. What interventions should the nurse most likely
prioritize?
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 - ✔️ Ans: C
Feedback:
Adolescent girls are considered to be at high risk for nutritional disorders.
Increasing calcium intake and promoting a balanced diet will provide the
necessary vitamins and minerals. If adolescents are diagnosed with eating
disorders early, the recovery chances are increased. The question presents
no information that indicates a need for decreasing her calories. There is
no apparent need for an increase in BMI. A food diary is used for assessing
eating habits, but the question asks for teaching factors related to good
nutrition.
2. A nurse is conducting a health assessment of an adult patient when the
patient asks, Why do you need all this health information and who is going
to see it? What is the nurses best response?
A) Please do not worry. It is safe and will be used only to help us with your
care. Its accessible to a wide variety of people who are invested in your
health.
B) It is good you asked and you have a right to know your information
helps us to provide you with the best possible care, and your records are in
a secure place.
C) Your health information is placed on secure Web sites to provide easy
access to anyone wishing to see your medical records. This ensures
continuity of care.
,D) Health information becomes the property of the hospital and we will
make sure that no one sees it. Then, in 2 years, we destroy all records and
the process starts over. - ✔️ Ans: B
Feedback: Whenever information is elicited from a person through a health
history or physical examination, the person has the right to know why the
information is sought and how it will be used. For this reason, it is
important to explain what the history and physical examination are, how
the information will be obtained, and how it will be used. Medical records
allow access to health care providers who need the information to provide
patients with the best possible care, and the records are always held in a
secure environment. Telling the patient not to worry minimizes the
patients concern regarding the safety of his or her health information and a
wide variety of people should not have access to patients health
information. Health information should not be placed on Web sites and
health records are not destroyed every 2 years.
3. The nurse is performing an admission assessment of a 72-year-old
female patient who understands minimal English. An interpreter who
speaks the patients language is unavailable and no members of the care
team speak the language. How should the nurse best perform data
collection?
A) Have a family member provide the data.
B) Obtain the data from the old chart and physicians assessment.
C) Obtain the data only from the patient, prioritizing aspects that the
patient understands.
D) Collect all possible data from the patient and have the family
supplement missing details. - ✔️ Ans: D
Feedback:
The informant, or the person providing the information, may not always be
the patient. The nurse can gain information from the patient and have the
family provide any missing details. The nurse should always obtain as
much information as possible directly from the patient. In this case, it is not
likely possible to get all the information needed only from the patient.
4. You are the nurse assessing a 28-year-old woman who has presented to
the emergency department with vague complaints of malaise. You note
bruising to the patients upper arm that correspond to the outline of fingers
as well as yellow bruising around her left eye. The patient makes minimal
, eye contact during the assessment. How might you 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? - ✔️ Ans: A
Feedback:
Few patients will discuss the topic of abuse unless they are directly asked.
Therefore, it is important to ask direct questions, such as, Is anyone
physically hurting you? The other options are incorrect because they are
not the best way to illicit information about possible abuse in a direct and
appropriate manner.
5. You are the nurse performing a health assessment of an adult male
patient. The man states, The doctor has already asked me all these
questions. Why are you asking them all over again? What is your best
response?
A) This history helps us determine what your needs may be for nursing
care.
B) You are right, this may seem redundant and Im sure that its frustrating
for you.
C) I want to make sure your doctor has covered everything thats important
for your treatment.
D) I am a member of your health care team and we want to make sure that
nothing falls through the cracks. - ✔️ Ans: A
Feedback:
Regardless of the assessment format used, the focus of nurses during data
collection is different from that of physicians and other health team
members. Explaining to the patient the purpose of the nursing assessment
creates a better understanding of what the nurse does. It also gives the
patient an opportunity to add his or her own input into the patients care
plan. The nurse should address the patients concerns directly and avoid
casting doubt on the thoroughness of the physician.
6. You are taking a health history on an adult patient who is new to the
clinic. While performing your assessment, the patient informs you that her
mother has type 1 diabetes. What is the primary significance of this
information to the health history?
A) The patient may be at risk for developing diabetes.
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