Chapter 44: Nutrition Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank, Exams of Nursing

Download Chapter 44: Nutrition Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank and more Exams Nursing in PDF only on Docsity! Chapter 44: Nutrition Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank MULTIPLE CHOICE 1. While doing a nutritional assessment of a low-income family, the community health nurse determines the family’s diet is inadequate in protein content. The nurse suggests which of the following foods to increase protein content with little increase in the food budget? 1 Oranges and potatoes 2 Potatoes and rice 3 Rice and macaroni 4 Peas and beans ANS: 4 For families on limited budgets, substitutes can be used. For example, bean or cheese dishes can often replace meat in a meal. Peas and lentils are also inexpensive food sources of protein. Oranges and potatoes are not high in protein content. Potatoes and rice are sources of carbohydrates, not protein. Rice and macaroni are carbohydrates and are not high in protein. PTS: 1 DIF: A REF: 1087 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 2. A client is suspected of having a fat-soluble vitamin deficiency. To assist the client with this deficiency, the nurse informs the client that: 1 “More exposure to sunlight and drinking milk could solve your nutritional problem 2 “Eating more pork, fish, eggs, and poultry will increase your vitamin B complex in 3 “Increasing your protein intake will increase your negative nitrogen imbalance” 4 “Decreasing your triglyceride levels by eating less saturated fats would be a good h intervention for you” ANS: 1 The fat-soluble vitamins are A, D, E, and K. With the exception of vitamin D, which can be obtained through exposure to sunlight, these vitamins are provided through dietary intake, including fortified milk. The B vitamins are not fat-soluble; they are water-soluble vitamins. Increasing protein intake will improve (decrease) a negative nitrogen imbalance, not increase it. Furthermore, increasing protein intake does not address the problem of a fat-soluble vitamin deficiency. PTS: 1 DIF: C REF: 1088 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 3. The client is diagnosed with malabsorption syndrome (celiac disease). In teaching about the gluten-free diet, the nurse informs the client to avoid: 1 Citrus fruits 2 Vegetables 3 Red meats 4 Wheat products ANS: 4 The treatment of malabsorption syndromes, such as celiac disease, includes a gluten-free diet. Gluten is present in wheat, rye, barley, and oats. Citrus fruits, vegetables, and red meat do not contain gluten. PTS: 1 DIF: A REF: 1126 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 7. The nurse is discussing dietary intake with a client who is human immunodeficiency virus (HIV) positive. The nurse informs the client that the diet will include a: 1 Restriction of potassium, phosphate, and sodium 2 Reduction in carbohydrate intake 3 Decreased protein and increased folic acid intake 4 Reduction in fat with smaller, more frequent meals ANS: 4 HIV-infected clients typically experience body wasting and severe weight loss. Restorative care for these clients focuses upon maximizing kilocalories and nutrients. Low-fat diets and small, frequent, nutrient- dense meals may be better tolerated. There is no need to restrict potassium, phosphate, and sodium in the client with HIV infection. The client with HIV infection does not need to reduce carbohydrate or protein or increase folic acid intake. PTS: 1 DIF: A REF: 1110 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort /Nutrition and Oral Hydration 8. Which of the following should the nurse do first when introducing a feeding to a client with an indwelling gavage tube? 1 Irrigate the tube with normal saline solution. 2 Check to see that the tube is properly placed. 3 Place the client in a supine position. 4 Introduce some water before giving the liquid nourishment. ANS: 2 Before introducing a feeding through an indwelling gavage tube for enteral nutrition, it is essential that the nurse check to see that the tube is properly placed. It is not necessary to irrigate the tube with normal saline. The client’s head should be elevated 30 to 45 degrees to help prevent the chance of aspiration. The tube may be flushed with 30 mL of water before initiating the feeding. However, the nurse should first verify correct tube placement. PTS: 1 DIF: C REF: 1113-1116 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 9. The nurse is caring for a client who is receiving parenteral nutrition (PN). Which of the following is an appropriate nursing intervention when administering parenteral nutrition to a client? 1 Begin the infusion rates at 100 to 150 mL/hour. 2 Maintain a consistent infusion rate. 3 Change the infusion tubing once a week. 4 Monitor protein levels daily. ANS: 2 The infusion should be maintained at a consistent rate. If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up, because this could lead to osmotic diuresis and dehydration. An infusion should not be discontinued abruptly, because it may cause hypoglycemia. An initial rate of 40 to 60 mL/hr is recommended. To avoid infection, the infusion tubing should be changed every 24 hours with lipids and every 48 hours when lipids are not infused. Protein levels do not need to be monitored daily. The client should be weighed daily until maximum administration rate is reached and maintained for 24 hours; then weigh the client 3 times per week. PTS: 1 DIF: C REF: 1121 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 10. Before inserting a small-bore nasogastric tube for enteral nutrition, the nurse correctly tells the client: 1 “The tube will feel uncomfortable and may make you gag at times when I am inser 2 “We will mark this tube from the end of your nose to your umbilicus to obtain the r length for insertion” 3 “Please hold your breath when I insert this small tube through your nose down into stomach” 4 “Please tilt your head back after the tube passes the nasopharynx.” ANS: 1 The procedure should be explained to the client, including how to communicate during intubation by raising his or her index finger to indicate gagging or discomfort. This will help reduce anxiety and help the client to assist in insertion. The length of the tube to be inserted is measured from the tip of the nose, to the earlobe, to the xiphoid process of the sternum. The client should be told to mouth-breathe and swallow during the procedure. The client should not hold his or her breath. The nurse should instruct the client to flex the head toward the chest after the tube has passed the nasopharynx. PTS: 1 DIF: C REF: 1113 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 11. A client is seen in the outpatient clinic for follow-up of a nutritional deficiency. In planning for the client’s dietary intake, the nurse includes a complete protein, such as: 1 Eggs 2 Oats PTS: 1 DIF: A REF: 1096 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 15. Which of the following would the nurse expect to see offered on a full liquid diet? 1 Custard 2 Pureed meats 3 Soft fresh fruit 4 Canned soup ANS: 1 Custard is included in a full liquid diet. Pureed meats are allowed in a pureed diet, not a full liquid diet. Soft fresh fruit is not included in a full liquid diet. Fresh fruit is often part of a high-fiber diet. Cooked or canned fruits are allowed on a mechanical soft diet. Canned soup is not part of full liquid diet because it may contain noodles or rice or vegetables. Soups are allowed on a mechanical soft diet. PTS: 1 DIF: A REF: 1111 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 16. During an enteral tube feeding, the client complains of abdominal cramping and nausea. The nurse should: 1 Cool the formula 2 Remove the tube 3 Use a more concentrated formula 4 Decrease the administration rate ANS: 4 If the client begins to experience abdominal cramping and nausea during an enteral tube feeding, the nurse should decrease the administration rate to increase tolerance. Administration of cold formula may cause abdominal cramping and nausea. The formula is best tolerated at room temperature. The nurse should not remove the tube if the client complains of abdominal cramping and nausea. The formula may need to be diluted if the client is complaining of abdominal cramping and nausea. PTS: 1 DIF: B REF: 1117 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 17. A client is diagnosed with a peptic ulcer and has come to the primary health care provider for a follow-up visit. The client asks the nurse what foods are safe to add to his diet. An appropriate response by the nurse is to inform the client that which of the following may be added to the diet? 1 Citrus juices 2 Green vegetables 3 Frequent glasses of milk 4 Unlimited decaffeinated coffee ANS: 2 The client diagnosed with a peptic ulcer may be allowed to add green vegetables to his diet. The client with a peptic ulcer should avoid foods that increase stomach acidity, such as caffeine, decaffeinated coffee, frequent milk intake, citric acid juices, and certain seasonings (hot chili peppers, chili powder, black pepper). Smoking, alcohol, and aspirin are also discouraged. PTS: 1 DIF: A REF: 1126 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 18. When teaching the parents of a toddler about safe finger foods, the nurse suggests trying which of the following? 1 Nuts 2 Popcorn 3 Cheerios 4 Hot dogs ANS: 3 Cheerios are an appropriate finger food for a toddler or preschool child. Nuts, popcorn, and hot dogs have been implicated in choking deaths and should be avoided. If hot dogs are given to this age child, they should be cut up into irregularly shaped pieces, such as long strips. PTS: 1 DIF: A REF: 1092 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 19. Which of the following is accurate nutritional information that the nurse should share with the parents of an adolescent child? 1 Girls require less protein. 2 Boys require additional iron. 3 Vitamin B needs are decreased. 4 Energy and caloric needs are decreased. ANS: 2 Adolescent boys require additional iron for muscle development. Daily requirements of protein increase for both adolescent boys and adolescent girls. B complex vitamins are needed to support heightened metabolic activity. Energy and caloric needs are increased to meet greater metabolic demands of growth during the adolescent period. until the position is radiographically confirmed. Aseptic technique, not sterile technique, is used during the administration of feedings. An initial rate of 40 to 60 mL/hr is recommended, and the rate is gradually increased. The rate of administration is not the priority. The nurse must first confirm correct placement of the catheter. A single container of PN should hang no longer than 24 hours; lipids no more than 12 hours. The nurse must first confirm correct placement of the catheter before any infusion is begun. PTS: 1 DIF: C REF: 1123 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 23. A client has been receiving tube feedings and is tolerating them very well. The health care provider determines that the rate of the intermittent tube feedings may be advanced. The nurse prepares to: 1 Increase the feedings by 50 mL/day 2 Start an isotonic formula at half strength 3 Infuse a bolus feeding over 5 to 10 minutes 4 Begin feedings with 250 to 500 mL at each interval ANS: 1 When a client is tolerating tube feedings well, the nurse should expect the health care provider to order the feedings to be increased by 50 mL/day to achieve needed volume and calories in six to eight feedings. Formula is started at full strength for isotonic formulas. Intermittent feedings are allowed to infuse over at least 20 to 30 minutes. Feedings should be begun with no more than 150 to 250 mL at one time. PTS: 1 DIF: A REF: 1123 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 24. The nurse is aware that there are medications that are taken that alter the client’s taste and may influence the dietary intake. In reviewing the medications taken by the clients on the unit, the nurse will consult with the nutritionist to develop a palatable meal plan for the client taking: 1 Ampicillin 2 Morphine 3 Furosemide 4 Acetaminophen ANS: 1 Ampicillin may cause an alteration in taste. Opiates, such as morphine, cause decreased peristalsis and may result in constipation. Decreased drug absorption may occur when diuretics, such as furosemide, are administered with food. Decreased acetaminophen absorption may occur if administered with food. Overdose of acetaminophen is associated with liver failure. Morphine, furosemide, and acetaminophen do not affect the client’s sense of taste. PTS: 1 DIF: C REF: 1097 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity Basic Care and Comfort/Nutrition and Oral Hydration 25. Food safety is a concern of a group of adults attending the community health clinic. The participants identify to the nurse that they have seen a lot of reports on television about Escherichia coli and how dangerous it can be. When asked where the bacteria comes from, the nurse responds that a potential source of E. coli is: 1 Sausage 2 Soft cheeses 3 Milk products 4 Ground beef ANS: 4 PTS: 1 DIF: C REF: 1087 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 29. The nurse is discussing food selection with a client who recently experienced a partial-thickness burn over 20% of her body. The client expresses a reluctance to ingest a large amount of carbohydrates because she successfully lost 50 pounds and does not want to regain the weight. The most therapeutic response to the client’s nutritional needs is: 1 “Don’t be concerned about regaining the weight until your burns have healed.” 2 “You need a huge amount of calories to heal, so there won’t be a weight gain.” 3 “You will experience a nitrogen imbalance if there aren’t enough carbohydrates in diet.” 4 “The extra carbohydrates will be utilized for energy so that your protein can be sav repair of your skin.” ANS: 4 Negative nitrogen balance occurs when the body loses more nitrogen than the body gains; for example, with infection, sepsis, burns, fever, starvation, head injury, and trauma. Nutrition during this period needs to provide nutrients to put clients into positive nitrogen balance for healing. Carbohydrates are the main source of energy in the diet. The remaining options concentrate more on the weight gain issue than the energy need. PTS: 1 DIF: C REF: 1087 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 30. A client with a family history of cancer is discussing the effects of free radicals on body cells and tissue. Which of the following responses is the most therapeutic answer to the client’s question, “What can I do to protect against free radicals?” 1 “Eat foods like blueberries, oranges, almonds, and carrots; they fight free radicals.” 2 “I can give you some literature on which foods are highest in free- radical fighters.” 3 “Research seems to support the positive role vitamins A, C, and E play in neutralizi radicals.” 4 “Foods that contain vitamins A, C, and E as well as beta-carotene seem to combat t of free radicals.” ANS: 4 Certain vitamins are currently of interest in their role as antioxidants. These vitamins neutralize substances called free radicals, which produce oxidative damage to body cells and tissues. Researchers believe that oxidative damage increases a person’s risk for various cancers. These vitamins include beta-carotene and vitamins A, C, and E. The remaining options oversimplify the response or give very unspecific information. PTS: 1 DIF: C REF: 1088 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 31. The nurse is discussing vitamin supplements with a client who is an amateur body builder. Which of the following statements by the nurse shows the greatest understanding concerning the risk for hypervitaminosis? 1 “Vitamins are important to proper body building and repair, but be aware that you c overdose and harm yourself.” 2 “Fat-soluble vitamins are stored in the body’s fat reserves, so be careful not to take vitamins A, D, E, and K.” 3 “Water-soluble vitamins are not stored in the body like fat-soluble ones, so it’s less overdose on vitamin C and the B complex.” 4 “I realize vitamin supplements are a factor in your training, but be aware of daily requirements so you don’t overdose, especially the fat-soluble vitamins.” ANS: 4 The fat-soluble vitamins (A, D, E, and K) are stored in the fatty compartments of the body. Hypervitaminosis of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food, and large intake of fish oils. The water-soluble vitamins, vitamin C and the B complex (which is eight vitamins), are not stored, so these need to be provided in the daily food intake. Although water-soluble vitamins are not stored, toxicity can still occur. The remaining option is not incorrect but is not as inclusive as the answer. PTS: 1 DIF: C REF: 1088 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 32. Which of the following statements reflects the best understanding of the benefits of breast-feeding related to the infant’s health and wellness? 1 “My husband and I both have food allergies, but she won’t be allergic to my breast 2 “The antibodies she gets will help keep her immunized from many illnesses for up first birthday.” 3 “I can spend so much more time with her because I have to devote my attention to I nurse.” 4 “It’s so convenient, no formula preparation, no bottles to wash and fill, no packing outings; its great.” ANS: 1 Breast-feeding benefits include the following: reduced food allergies and intolerances; fewer infant infections; easier digestion; convenient; always correct temperature, available, and fresh; economical, because it is less expensive than formula; and increased time for mother and infant interaction. The other options are not incorrect but do not focus on health benefits for the infant as directly as the answer. TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 36. The nurse is questioning a newly admitted client regarding his dietary history. Which of the following questions asked by the nurse is most likely to secure additional pertinent information regarding the client’s statement, “I think I’m allergic to peanuts”? 1 “What happens when you eat peanuts?” 2 “What makes you think you are allergic to peanuts?” 3 “When did you first notice this sensitivity to peanuts?” 4 “A peanut allergy is very serious; how do you manage to avoid them?” ANS: 1 Asking the client to describe the reactions to a particular food allows for a more thorough discussion than does any of the other options. Some options are more directed at the management rather than securing additional information regarding the reaction itself. PTS: 1 DIF: C REF: 1101 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 37. The nurse is counseling a client undergoing chemotherapy. The client has shared with the nurse that the client does not have much of an appetite and is worried about not getting enough nutrients. Which of the following statements by the nurse addresses the client’s concerns? 1 “Let me share information regarding how a high-calorie diet can help prevent you losing weight.” 2 “Let me share information about high-nutrient-density foods to help you make cho 3 “You need to avoid carbohydrates in your diet.” 4 “Your body needs a lot of protein right now to prevent muscle loss.” ANS: 2 Foods are sometimes described according to their nutrient density, the proportion of essential nutrients to the number of kilocalories. High- nutrient-density foods, such as fruits and vegetables, provide a large number of nutrients in relationship to kilocalories. The client did not express a concern about weight loss but is asking about nutrition. Protein provides energy, but because of protein’s essential role in growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources. Each gram of carbohydrate produces 4 kcal and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, erythrocyte and leukocyte production, and cell function of the renal medulla. When there is sufficient carbohydrate in the diet to meet the energy needs of the body, protein is spared as an energy source. PTS: 1 DIF: B REF: 1111 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 38. A 41-year-old female client has been dieting to lose weight. Which of the following statements indicates that the client needs additional teaching regarding a healthy weight-loss plan? 1 “I have based my diet on the food pyramid.” 2 “I am planning to lose between 1 and 2 pounds per week.” 3 “I need to eliminate all fat from my diet.” 4 “I plan to begin an exercise program as soon as I see my health care provider.” ANS: 2 Total fat intake should be between 20% and 35% of total calories with most fats coming from polyunsaturated or monounsaturated fatty acids. The Food Guide Pyramid is a basic guide for buying food and meal preparation. This basic system provides for diets ranging from 1600 to 2800 kcal/day. Losing weight at a slow rate is healthier than taking it off quickly. In general, when energy requirements are completely met by kilocalorie intake in food, weight does not change. When the kilocalories ingested exceed a person’s energy demands, the individual gains weight. If the kilocalories ingested fail to meet a person’s energy requirements, the individual loses weight. PTS: 1 DIF: B REF: 1109 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 39. The nurse is caring for a 5-kg 8-month-old infant admitted to the hospital by the health care provider, who was concerned about the infant’s low weight. The infant’s birth weight was 3.5 kg. The nurse knows that on average an infant doubles his or her birth weight at what age? 1 2 to 3 months 2 4 to 5 months 3 6 to 7 months 4 8 to 9 months ANS: 2 The infant usually doubles birth weight at 4 to 5 months and triples it at 1 year. PTS: 1 DIF: C REF: 1087 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 40. The nurse is caring for a 6-kg 4-month-old infant who is hospitalized with a respiratory infection. The nurse knows that an infant this age needs approximately 108 kcal/kg of body weight. The nurse also understands that human breast milk provides approximately 20 kcal/oz. About how much breast milk does the nurse need to feed the infant rate slows with age. However, vitamin and mineral requirements remain unchanged from middle adulthood. PTS: 1 DIF: B REF: 1094 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 44. The nurse is counseling a 64-year-old client that it is important to eat plenty of fruits and vegetables, but the client should avoid which of the following because it can inhibit the absorption of some drugs? 1 Oranges 2 Grapefruit 3 Pineapple 4 Asparagus ANS: 2 Caution older adults to avoid grapefruit and grapefruit juice because these will decrease absorption of many drugs. PTS: 1 DIF: C REF: 1086 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 45. When menu planning for a newly diagnosed diabetic client who practices Judaism, the nurse should avoid which of the following dishes? 1 Vegetable beef soup 2 Chicken pot pie 3 Beef lasagna 4 Scrambled eggs ANS: 3 Judaism prohibits the mixing of milk or dairy products with meat dishes, and the beef lasagna has both meat and cheese in it. PTS: 1 DIF: B REF: 1086 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 46. The nurse caring for a 55-year-old male client knows that due to his religious beliefs he is most likely a vegetarian. Which of the following religions encourage vegetarianism? 1 Church of Jesus Christ of Latter-Day Saints 2 Seventh-Day Adventist 3 Judaism 4 Pentecostal ANS: 2 Vegetarian or ovolactovegetarian diets are encouraged in followers of the Seventh-Day Adventist Church. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration MULTIPLE RESPONSE 1. The nurse is delegating the feeding of an older adult client to ancillary personnel. Which of the following should the nurse include in the instructions as possible warning signs of dysphagia (difficulty swallowing)? (Select all that apply.) 1 Delay in swallowing food 2 Easily triggered gag reflex 3 Absence of a gag reflex 4 Uncoordinated speech 5 Disinterest in eating 6 Pocketing food ANS: 1, 2, 3, 4, 6 Signs of dysphagia include the following: cough during eating; change in voice tone or quality after swallowing; abnormal movements of the mouth, tongue, or lips; and slow, weak, imprecise, or uncoordinated speech. Abnormal gag reflex, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak consistently are other signs of dysphagia. PTS: 1 DIF: A REF: 1092 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 2. Which of the following clients has an identified factor that is affecting the client’s energy requirements? (Select all that apply.) 1 A 27-year-old diagnosed anorexic client 2 A 21-year-old college football quarterback 3 A 73-year-old recovering from hip surgery 4 A 39-year-old who is currently menstruating 5 A 4-year-old with a temperature of 102.2° F rectally 6 A 50-year-old diagnosed with chronic depression ANS: 1, 2, 3, 4, 5 Factors such as age, body mass, gender, fever, starvation, menstruation, illness, injury, infection, activity level, or thyroid function affect energy requirements. There is no direct connection between depression and energy requirements. 3 Economical source of nutrients 4 Minimal digestive system upsets 5 Less risk related to food allergies 6 Encourages family-infant bonding ANS: 1, 2, 3, 4, 5 Benefits of breast-feeding include reduced food allergies and intolerances; fewer infant infections; easier digestion; convenient; always correct temperature, available, and fresh; economical, because it is less expensive than formula; and increased time for mother and infant interaction, although it does not contribute to family-infant bonding. PTS: 1 DIF: A REF: 1094 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 5. Which of the following factors are believed to contribute to the prevalence of overweight children seen in America today? (Select all that apply.) 1 Unavailability of high-nutrient-density foods 2 Reliance on food as a stress-coping mechanism 3 Decline in an interest in physically active hobbies 4 Reliance on fast foods for major portion of daily diet 5 Increased interest in passive, technology-driven activities 6 Reduced supervision in the home, especially during after-school hours ANS: 2, 3, 4, 5, 6 A combination of factors contributes to the problem, including a diet rich in high-calorie foods, inactivity, genetic predisposition, use of food as a coping mechanism for stress or boredom, and family and social factors. There is not a scarcity of healthy foods in this country. PTS: 1 DIF: C REF: 1094 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 6. Older adults are at an increased risk for dehydration from a variety of risk factors that include a decreased thirst drive. Which of the following should a nurse include in a discussion with members of a senior center regarding the signs of dehydration? (Select all that apply.) 1 Dry, hot skin 2 Memory lapses 3 Dry, cracked lips 4 Weak, slow pulsec 5 Physical weakness 6 Decreased urination ANS: 1, 2, 3, 5, 6 Symptoms of dehydration in older adults include confusion; weakness; hot, dry skin; furrowed tongue; rapid pulse; and high urinary sodium level. PTS: 1 DIF: A REF: 1096 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 7. Which of the following assessment findings in an older adult increases the individual’s risk for poor nutrition? (Select all that apply.) 1 Living on a Social Security income check 2 Did not graduate from high school 3 Is easily tired by activity 4 Living in a group home 5 Chronically depressed 6 Recently widowed ANS: 1, 2, 3, 5, 6 Malnutrition in older adults has multiple causes, such as income, educational level, physical functioning level to meet activities of daily living (ADLs), loss, dependency, loneliness, and transportation. Living in a managed environment is not a risk factor for poor nutrition. PTS: 1 DIF: C REF: 1096 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration