Terms in this set (26)
1. An 82-year-old Latino patient with mild protein-calorie malnutrition shares a home with his spouse and adult daughter .
When developing a teaching plan to improve the patient's nutrition, it will be most important for the nurse to obtain
information about
a. food preferences of the spouse and adult child.
b. who shops for groceries and cooks.
c. the number of meals per day the patient eats.
d. foods that are culturally significant for the patient.
B
Rationale: The family member who shops for groceries and cooks will be in control of the patient's diet, so the nurse will need to ensure that this family
member is involved in any teaching or discussion about the patient's nutritional needs. The other information will also be assessed and used but will not
be useful in meeting the patient's nutritional needs unless nutritionally appropriate foods are purchased and prepared.
Cognitive Level: Application Text Reference: p. 951
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
2. A patient who weighs 145 pounds (66 kg) asks the nurse how much protein should be included in the daily diet. The
nurse recommends that the diet should include a minimum of _____ g protein.
a. 36
b. 53
c. 75
d. 98
B
Rationale: The recommended daily protein intake is 0.8 to 1 g/kg of body weight, which for this patient is 66 kg 0.8 g = 52.8 or 53 g/day for this patient.
Cognitive Level: Application Text Reference: p. 949
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance
3. During assessment of a patient who is a vegan, the nurse observes for signs of nutritional deficiency . The most
common nutritional deficiency related to a strict vegan diet would be manifested by
a. muscle wasting.
b. bleeding gums.
c. pallor and changes in sensation and movement of the extremities.
d. dry , scaly skin and cracked, painful oral mucous membranes.
C
Rationale: Cobalamin (vitamin B12) cannot be obtained in foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency , such as
anemia and peripheral neuropathy . The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan
diet.
Cognitive Level: Application Text Reference: pp. 950-951
Nursing Process: Assessment NCLEX: Physiological Integrity
4. The nurse teaches a patient who is being stabilized on a therapeutic dose of warfarin (Coumadin) not to alter the
normal dietary intake of green, leafy vegetables, dairy products, or meats, primarily because these foods
a. are a source of vitamin K and may alter the action of warfarin.
b. decrease the absorption of warfarin.
c. have a natural anticoagulant ef fect.
d. affect the activity of bowel bacteria responsible for vitamin K production.
A
Rationale: Because warfarin activity is af fected by the level of vitamin K, the patient's intake of vitamin K-rich foods should be consistent. The absorption of
warfarin is not af fected by these foods. The foods do not have an anticoagulant ef fect or impact on the bowel bacteria activity .
Cognitive Level: Application Text Reference: p. 954
Nursing Process: Implementation NCLEX: Physiological Integrity 5. A 72-year-old patient with massive infection is 5 ft 2 in (155 cm) tall and weighs 92 pounds (42 kg). Laboratory results
include hemoglobin 10.5 g/dl (105 g/L) and albumin 2.0 g/dl (20 g/L). Which additional information will be most useful
when the nurse is determining the patient's nutritional status?
a. Blood pressure
b. Level of consciousness
c. Presence of edema
d. Food allergies
C
Rationale: Edema occurs when serum albumin levels and plasma oncotic pressure decrease, as occurs when a stressor such as infection is imposed on
pre-existing poor nutritional status. The blood pressure and level of consciousness are not directly af fected by protein-calorie malnutrition. Food allergies
are not an indicator of nutritional status.
Cognitive Level: Application Text Reference: pp. 952, 956
Nursing Process: Assessment NCLEX: Physiological Integrity
6. When using a nutrition screening tool, the nurse can identify a patient at nutritional risk without further assessment
when the patient has
a. pressure ulcers.
b. had a recent hip fracture.
c. been vomiting for 3 days.
d. had recent surgery .
A
Rationale: Malnutrition is a major risk factor for pressure ulcers; therefore, the presence of a pressure ulcer indicates that the patient is at nutritional risk.
The other patient diagnoses are not independent risk factors for poor nutrition.
Cognitive Level: Comprehension Text Reference: p. 957
Nursing Process: Assessment NCLEX: Physiological Integrity
7. In evaluating a patient outcome of "chooses high-protein foods," the nurse knows the outcome has been met when for
lunch the patient selects from the hospital menu
a. bacon and tomato sandwich, bean soup, and cof fee with cream.
b. peanut butter and jelly sandwich, French fries, and whole milk.
c. barbequed chicken breast sandwich, fruit yogurt, and skim milk.
d. chicken noodle soup, grilled cheese sandwich, and apple juice.
C
Rationale: The poultry and dairy selected are all high in complete protein. Although the other responses have some high protein foods, they are not as
high in protein.
Cognitive Level: Application Text Reference: p. 950
Nursing Process: Evaluation NCLEX: Physiological Integrity
8. A high-calorie, high-protein diet is provided for a patient with a fractured hip and severe protein-calorie depletion, but
the patient eats only about 50% of each meal tray and then complains of feeling tired. The nurse will plan to
a. arrange for smaller portions to be served on patient trays.
b. serve multiple small feedings of high-calorie, high-protein foods.
c. give continuous tube feedings of liquid nutritional supplements.
d. administer intravenous feeding with parenteral nutrition solutions.
B
Rationale: Eating small amounts of food frequently throughout the day is less fatiguing and will improve the patient's ability to take in more nutrients.
Smaller serving sizes will not improve patient nutritional intake. Tube feedings or parenteral nutrition (PN) may be needed if the patient is unable to take in
enough nutrients orally , but increasing the oral intake should be attempted first.
Cognitive Level: Application Text Reference: p. 958
Nursing Process: Planning NCLEX: Physiological Integrity
1. An 82-year-old Latino patient with mild protein-calorie malnutrition shares a home with his spouse and adult daughter .
When developing a teaching plan to improve the patient's nutrition, it will be most important for the nurse to obtain
information about
a. food preferences of the spouse and adult child.
b. who shops for groceries and cooks.
c. the number of meals per day the patient eats.
d. foods that are culturally significant for the patient.
B
Rationale: The family member who shops for groceries and cooks will be in control of the patient's diet, so the nurse will need to ensure that this family
member is involved in any teaching or discussion about the patient's nutritional needs. The other information will also be assessed and used but will not
be useful in meeting the patient's nutritional needs unless nutritionally appropriate foods are purchased and prepared.
Cognitive Level: Application Text Reference: p. 951
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
2. A patient who weighs 145 pounds (66 kg) asks the nurse how much protein should be included in the daily diet. The
nurse recommends that the diet should include a minimum of _____ g protein.
a. 36
b. 53
c. 75
d. 98
B
Rationale: The recommended daily protein intake is 0.8 to 1 g/kg of body weight, which for this patient is 66 kg 0.8 g = 52.8 or 53 g/day for this patient.
Cognitive Level: Application Text Reference: p. 949
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance
3. During assessment of a patient who is a vegan, the nurse observes for signs of nutritional deficiency . The most
common nutritional deficiency related to a strict vegan diet would be manifested by
a. muscle wasting.
b. bleeding gums.
c. pallor and changes in sensation and movement of the extremities.
d. dry , scaly skin and cracked, painful oral mucous membranes.
C
Rationale: Cobalamin (vitamin B12) cannot be obtained in foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency , such as
anemia and peripheral neuropathy . The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan
diet.
Cognitive Level: Application Text Reference: pp. 950-951
Nursing Process: Assessment NCLEX: Physiological Integrity
4. The nurse teaches a patient who is being stabilized on a therapeutic dose of warfarin (Coumadin) not to alter the
normal dietary intake of green, leafy vegetables, dairy products, or meats, primarily because these foods
a. are a source of vitamin K and may alter the action of warfarin.
b. decrease the absorption of warfarin.
c. have a natural anticoagulant ef fect.
d. affect the activity of bowel bacteria responsible for vitamin K production.
A
Rationale: Because warfarin activity is af fected by the level of vitamin K, the patient's intake of vitamin K-rich foods should be consistent. The absorption of
warfarin is not af fected by these foods. The foods do not have an anticoagulant ef fect or impact on the bowel bacteria activity .
Cognitive Level: Application Text Reference: p. 954
Nursing Process: Implementation NCLEX: Physiological Integrity 5. A 72-year-old patient with massive infection is 5 ft 2 in (155 cm) tall and weighs 92 pounds (42 kg). Laboratory results
include hemoglobin 10.5 g/dl (105 g/L) and albumin 2.0 g/dl (20 g/L). Which additional information will be most useful
when the nurse is determining the patient's nutritional status?
a. Blood pressure
b. Level of consciousness
c. Presence of edema
d. Food allergies
C
Rationale: Edema occurs when serum albumin levels and plasma oncotic pressure decrease, as occurs when a stressor such as infection is imposed on
pre-existing poor nutritional status. The blood pressure and level of consciousness are not directly af fected by protein-calorie malnutrition. Food allergies
are not an indicator of nutritional status.
Cognitive Level: Application Text Reference: pp. 952, 956
Nursing Process: Assessment NCLEX: Physiological Integrity
6. When using a nutrition screening tool, the nurse can identify a patient at nutritional risk without further assessment
when the patient has
a. pressure ulcers.
b. had a recent hip fracture.
c. been vomiting for 3 days.
d. had recent surgery .
A
Rationale: Malnutrition is a major risk factor for pressure ulcers; therefore, the presence of a pressure ulcer indicates that the patient is at nutritional risk.
The other patient diagnoses are not independent risk factors for poor nutrition.
Cognitive Level: Comprehension Text Reference: p. 957
Nursing Process: Assessment NCLEX: Physiological Integrity
7. In evaluating a patient outcome of "chooses high-protein foods," the nurse knows the outcome has been met when for
lunch the patient selects from the hospital menu
a. bacon and tomato sandwich, bean soup, and cof fee with cream.
b. peanut butter and jelly sandwich, French fries, and whole milk.
c. barbequed chicken breast sandwich, fruit yogurt, and skim milk.
d. chicken noodle soup, grilled cheese sandwich, and apple juice.
C
Rationale: The poultry and dairy selected are all high in complete protein. Although the other responses have some high protein foods, they are not as
high in protein.
Cognitive Level: Application Text Reference: p. 950
Nursing Process: Evaluation NCLEX: Physiological Integrity
8. A high-calorie, high-protein diet is provided for a patient with a fractured hip and severe protein-calorie depletion, but
the patient eats only about 50% of each meal tray and then complains of feeling tired. The nurse will plan to
a. arrange for smaller portions to be served on patient trays.
b. serve multiple small feedings of high-calorie, high-protein foods.
c. give continuous tube feedings of liquid nutritional supplements.
d. administer intravenous feeding with parenteral nutrition solutions.
B
Rationale: Eating small amounts of food frequently throughout the day is less fatiguing and will improve the patient's ability to take in more nutrients.
Smaller serving sizes will not improve patient nutritional intake. Tube feedings or parenteral nutrition (PN) may be needed if the patient is unable to take in
enough nutrients orally , but increasing the oral intake should be attempted first.
Cognitive Level: Application Text Reference: p. 958
Nursing Process: Planning NCLEX: Physiological Integrity
