Jarvis Ch 12
The nurse recognizes which of these people is at greatest risk for undernutrition?
5-month-old infant
Which of these conditions is due to an inadequate intake of both protein and calories?
A. Bulimia
B. Obesity
C. Marasmus
D. Kwashiorkor
C. Marasmus
The nurse is evaluating a patient’s pain. Which is an example of acute pain?
A. Fibromyalgia
B. Arthritic pain
C. Kidney stones
D. Lower back pain
C. Kidney stones Correct
The nurse should measure rectal temperatures in which of these patients?
A. Older adult
B. Comatose adult
C. School-age child
D. Patient receiving oxygen by nasal cannula
B. Comatose adult Correct
The nurse is performing a general survey. Which action is a component of the general survey?
A. Observing the patient’s body stature and nutritional status Correct
B. Interpreting the subjective information the patient has reported
C. Measuring the patient’s temperature, pulse, respirations, and blood pressure
D. Observing specific body systems while performing the physical assessment
A. Observing the patient’s body stature and nutritional status Correct
The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group?
A. Maintaining adequate fat and caloric intake is important for a 1-year-old child.
B. The recommended dietary allowances for an infant are the same as for an adolescent.
C. The baby’s growth is minimal at this age; therefore, caloric requirements are decreased.
D. The baby should be placed on skim milk to decrease the risk for coronary artery disease when he or she grows older.
A. Maintaining adequate fat and caloric intake is important for a 1-year-old child.
The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of these foods are recommended?
A. Foods easy to hold such as hot dogs, nuts, and grapes
B. Foods that the child will eat, no matter what the food
C. Any food, as long as the rest of the family is eating it, too
D. Finger foods and nutritious snacks that cannot cause choking
D. Finger foods and nutritious snacks that cannot cause choking
The nurse is teaching a class on pain at a local retirement community. Which statement about the pain experienced by older adults should the nurse include in the instructions?
A. “Older adults must learn to tolerate pain.”
B. “Pain is a normal process of aging and is to be expected.”
C. “Pain indicates a pathologic condition or an injury and is not a normal process of aging.”
D. “Older individuals perceive pain to a lesser degree than do younger individuals.”
C. “Pain indicates a pathologic condition or an injury and is not a normal process of aging.”
When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult’s body temperature?
A. The body temperature of the older adult is lower than that of a younger adult.
B. An older adult’s body temperature is approximately the same as that of a young child.
C. Body temperature depends on the type of thermometer used.
D. In the older adult, the body temperature varies widely because of less effective heat control mechanisms.
A. The body temperature of the older adult is lower than that of a younger adult. Correct
Which of these guidelines should a nurse follow when measuring a patient’s weight?
A. The patient is always weighed wearing only his or her undergarments.
B. The type of scale does not matter, as long as the weights are similar from day to day.
C. The patient may leave on his or her jacket and shoes as long as these are documented next to the weight.
D. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
D. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
A pregnant woman is interested in breastfeeding her baby and asks several questions about the topic. Which statement by the nurse is appropriate?
A. “Babies who are breastfed often require supplemental vitamins.”
B. “Breastfeeding is best when also supplemented with bottle-feedings.”
C. “Breastfeeding is recommended for infants for the first 2 years of life.”
D. “Breast milk provides the nutrients necessary for growth, as well as natural immunity.”
D. “Breast milk provides the nutrients necessary for growth, as well as natural immunity.”
A patient is asked to indicate on a form how many times he eats a specific food. This method describes which of these tools for obtaining dietary information?
A. Food diary
B. Calorie count
C. 24-hour recall
D. Food-frequency questionnaire
D. Food-frequency questionnaire
The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system?
A. Visceral
B. Referred
C. Cutaneous
D. Neuropathic
D. Neuropathic
Which technique is correct when the nurse is assessing the radial pulse of a patient?
A. Palpate for 1 minute, if the rhythm is irregular.
B. Palpate for 15 seconds and multiply by 4, if the rhythm is regular.
C. Palpate for 2 full minutes to detect any variation in amplitude.
D. Palpate for 10 seconds and multiply by 6, if the rhythm is regular and the patient has no history of cardiac abnormalities.
A. Palpate for 1 minute, if the rhythm is irregular. Correct
The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
A. Measuring the infant’s length by using a tape measure
B. Weighing the infant by placing him or her on an electronic standing scale
C. Measuring the chest circumference at the nipple line with a tape measure
D. Measuring the head circumference by wrapping the tape measure over the nose and cheekbones
C. Measuring the chest circumference at the nipple line with a tape measure Correct
An older adult patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patient’s gums are swollen, ulcerated, and bleeding in some areas. The nurse suspects that the patient has what condition?
A. Rickets
B. Vitamin A deficiency
C. Linoleic-acid deficiency
D. Vitamin C deficiency
D. Vitamin C deficiency
what tool is the most comprehensive to assess dietary intake
food diary
When assessing a patient’s pain, the nurse records that the patient has visceral pain. Which condition would the patient have stated in order for the nurse document visceral pain?
A. A hip fracture
B. Cholecystitis
C. Second-degree burns
D. Pain after a leg amputation
B. Cholecystitis Correct
The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature–36° C; pulse–48 beats per minute; respirations–14 breaths per minute; blood pressure–104/68 mm Hg. Which statement is true concerning these results?
A. The patient is experiencing tachycardia.
B. These are normal vital signs for a healthy, athletic adult.
C. The patient’s pulse rate is not normal—his physician should be notified.
D. On the basis of these readings, the patient should return to the clinic in 1 week.
B. These are normal vital signs for a healthy, athletic adult. Correct
The nurse is performing a general survey of a patient. Which finding is considered normal?
A. Body mass index (BMI) of 20
B. When standing, the patient’s base is narrow.
C. The patient appears older than his stated age.
D. Arm span (fingertip to fingertip) is greater than the height.
A. Body mass index (BMI) of 20 Correct
A 50-year-old patient has been brought to the emergency department after a housemate found that the patient could not get out of bed alone. He has lived in a group home for years but for several months has not participated in the activities and has stayed in his room. The nurse assesses for signs of undernutrition, and an x-ray study reveals that he has osteomalacia. What deficiency is likely the cause?
A. Iron
B. Vitamin C
C. Riboflavin
D. Vitamin D and calcium
D. Vitamin D and calcium
During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color, which is an indication of a deficiency in what mineral and/or vitamin?
A. Iron
B. Riboflavin
C. Vitamin C
D. Vitamin D and calcium
B. Riboflavin
A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate?
A. Completing the physical examination first and then giving the pain medication
B. Telling the patient that the pain medication must wait until after the x-ray images are completed
C. Evaluating the full range of motion of the knee and then medicating for pain
D. Administering pain medication and then proceeding with the assessment
D. Administering pain medication and then proceeding with the assessment Correct
The nurse notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?
A. Yield a falsely low blood pressure
B. Yield a falsely high blood pressure
C. Be the same, regardless of cuff size
D. Vary as a result of the technique of the person performing the assessment
B. Yield a falsely high blood pressure Correct
During an examination, the nurse notices that a female patient has a round “moon” face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient likely has which condition?
A. Gigantism
B. Acromegaly
C. Cushing syndrome
D. Marfan syndrome
C. Cushing syndrome Correct